N&E GTA Stroke Region & Network Stakeholder Summary of Rehabilitation Standards Survey

Transcription

1 N&E GTA Region & Network Stakeholder Summary of ilitation Standards Survey This document provides a summary of the data from the Regional Partner Self Assessment Tool developed and administered by the GTA Network and the GTA regions of the Ontario System. The goal of these tools is to help organizations identify successes, challenges and capacities in meeting the relevant standards for stroke rehab developed by the GTA Network and the Ontario ilitation System Consensus Panel. Five tools were created, each corresponding to programs within the categories of Acute Care, In Patient ilitation High Tolerance, In Patient ilitation Low Tolerance, ilitation, and Community Based ilitation. The tools differed based on which standards were applicable to their programming within the continuum of Care. This report is organized according to the 0 Standards and their corollaries presented in the Consensus Panel Report. Table lists the participating organizations and programs and the tool type that was completed by each. There were a total of 3 responses Table. List of participating organizations Name of organization Name of Service/Program Survey Type # of Surveys Total x survey The Scarborough Hospital Acute Medicine/ Acute Sunnybrook Health Sciences General Medicine Acute Centre 3 Sunnybrook Health Sciences Acute stroke Acute 4 Centre 4 North York General Hospital Acute stroke Acute 5 North York General Hospital Community Based Community 6 Baycrest Moving On after Community MOST 7 North York General Hospital In - high 8 St.John's Hospital In - high 9 Baycrest ilitation Program In - high 3 0 North York General Hospital In - low Baycrest and Cognition Sunnybrook Health Sciences Centre Program Regional Team - North and East GTA 3 North York General Hospital The standards are organized into the six categories presented in the Consensus Panel Report. They are: 3

2 . Screening and Assessment (Standards to 5). Needs Definition (Standards 6 & 7) 3. Quality Care (Standards 8-) 4. Accessible Care (Standards 3-7) 5. Timely Care (Standard 8) 6. System Planning (Standard 9 & 0) Under each Theme, the relevant standards are listed with a frequency chart that displays the number of programs/organizations within each of the relevant service areas that have fully met, partially met or not met the standards in question, as self-assessed. Please note that frequencies within each standard do not sum to the total sample of 3 because not all 0 standards are relevant to all programs/organizations. Feedback and context comments provided by the respondents are appended to each. THEME - SCREENING AND ASSESSMENT AS PROPOSED IN THE SERVICE PROVISION MODEL, ASSESSMENTS ARE REQUIRED AT KEY POINTS ALONG THE CONTINUUM OF CARE Standard # All patients admitted to hospital with acute stroke will have an early initial rehabilitation assessment by relevant rehabilitation professionals as soon as possible after admission within the first 4-48 hours. Weekends will not limit time to assessment Please indicate if this standard is met for patient admitted to hospital but who remain in the emergency department after admission. Standard # Acute 3 (High (Low Not met Fully met

3 Challenges/Limitations/Fit within organization s strategic priorities: Able to achieve: Allied health assesses patients on the wards within 48 hours during the weekday. Not able to asses patients who are in the emergency. Physiotherapy able to assess patients on the weekend as time permits. No other allied health coverage on the weekends on the wards. Limitations: no staffing on the weekend for social work, OT, SLP on the wards. Limited physiotherapy coverage on the weekend. Limited pharmacy coverage on the weekend. Limited social work coverage in the emergency department on the weekend. Does not fit with the organizations priorities. (Sunnybrook Health Sciences Centre-General Medicine/Acute) Standard # All stroke survivors (excluding TIAs) who are not admitted to hospital or who are discharged home from acute care will undergo an ambulatory or home-based screening assessment, which includes a medical, functional and cognitive assessment, by professionals with expertise in stroke, within two weeks. Standard # Acute Based 3 (high 3 Not met Partially met Fully met Challenges/Limitations/Fit within organization s strategic priorities: No TIA clinic. Strategic priorities do not specifically identify this strategy/(the Scarborough Hospital-Acute Medicine) The Mechanism for re-access is based on review by the patient's own physician or geriatrician and based on the physician's evaluation and identified goals, referrals are made to the Community based rehab program (Baycrest- ilitation Program) 3

4 Challenges: Physicians refer to secondary prevention clinic sometimes at 3 month (Sunnybrook Health Sciences Centre - Regional Team - North and East GTA) Standard # 3a Survivors of a severe or moderate stroke who are not initially considered eligible for inpatient stroke rehabilitation, once in Ready, will be reassessed at regular intervals for their rehabilitation needs. Standard # 3a Acute Based Not met Fully met Corollary: Initiate rehab intervention as soon as possible and provide rehab to the extent that it is needed and the patient is able to tolerate. 0 Initiate rehab intervention as soon as possible Partially met Fully met Acute 4

5 Challenges/Limitations/Fit within organization s strategic priorities We have been able to asses all patients and provide limited treatment. Challenges/limitations: staffing limitations and acute care priorities. Does not fit with the organizations priorities. (Sunnybrook Health Sciences Centre-General Medicine/Acute ) Standard # 3b As clinically indicated, a primary care practitioner, CCAC case manager, physiatrist or relevant rehabilitation professional will conduct a periodic reassessment of rehabilitation needs of the stroke survivor at six weeks, three months, one year and as needed. This assessment and client goals will provide the basis for a comprehensive plan of care to be developed, implemented and updated with the stroke survivor and family/caregivers. Standard # 3b Acute Based Partially met Fully met Challenges/Limitations/Fit within organization s strategic priorities While in hospital- ongoing reassessment (North York General Hospital- Community Based ) Have only recently added a physiatrist to the regional stroke rehab team. Regional team members (i.e. physiotherapist) will conduct re-assessment at 6 weeks as indicated. (Sunnybrook Health Sciences Centre - Regional Team - North and East GTA) Ongoing assessment while in acute care (North York General Hospital- ) 5

6 Standard # 4 survivors should have a mechanism to access or re access the rehabilitation environment, if clinically indicated, regardless of the time that has elapsed since the stroke. Standard # Acute Based (high (low Not met Partially met Fully met Challenges/Limitations/Fit within organization s strategic priorities We have had difficulty, getting people to rehab who primary diagnosis is not stroke, but who have significant impairments from previous strokes; challenges: admission criteria of rehab facilities limited (North York General Hospital- Acute ) MOST, as a stroke self-management program provides group education and behaviour change support designed to help people with stroke move forward with their lives and community re-integration. Potential participants self-refer and a program requirement is that the active rehabilitation phase has been completed (Baycrest- Moving On after MOST) In an acute care setting difficult to place old CVA at new problems (North York General Hospital - ) St. John's provides a short stay intensive in-patient program and strokes less than 3 months are admitted. However, this varies on an outpatient basis and is based on rehab goals. Yes and no as per above reason. We do not have a low threshold long duration program nor do we have a complex care program (St.John's Hospital- /high Old CVA difficult to place in rehab facilities(north York General Hospital- /low 6

7 Clients can access the regional team at any point post discharge. (Sunnybrook Health Sciences Centre- Regional Team - North and East GTA) Tight criteria in rehab facilities; patients with old CVA/new problems when admissions are not easy to place (North York General Hospital- ) Standard # 5 related impairments status will be evaluated by rehabilitation professional trained in stroke rehabilitation using standardized, valid assessment. Standard # Acute Based (high 3 3 (low Partially met Fully met Challenges/Limitations/Fit within organization s strategic priorities Time limitation of staff; short length of stay(north York General Hospital- Acute ) As part of program evaluation for MOST, validated functional measures are completed along with validated quality of life and health impact related self-administered questionnaires. Functional measures done pre-post support review of the MOST exercise component while the questionnaires (pre-post) support review of the educational & health behaviour change component of the program (Baycrest- Moving On after MOST) 7

8 THEME - NEEDS DEFINITION FOR EACH STROKE SURVIVOR, A FORMAL PLAN BASED ON FINDINGS OF THE ASSESSMENT IDENTIFIES PATIENT AND FAMILY/CAREGIVERS GOALS AND REHABILITATION NEEDS Standard # 6 The interprofessional team will develop a comprehensive rehabilitation plan with each stroke survivor that reflects the severity of the stroke, the needs and goals of the stroke survivor, and the family/caregiver and home environment. Standard # Acute Based (high Partially met (low Fully met 3 8

9 A coordinated team approach is used at least one formal team meeting per week to discuss progress, goals and discharge plans. A coordinated team approach is used Based -high tolerance -low tolerance Fully met Partially met There is a focused interprofessional assessment to determine breadth deficits and rehab intensity required, preferably within the first 4-48 hours. Focused interprofessional assessment Acute (high Partially met Fully met 9

10 Challenges/Limitations/Fit within organization s strategic priorities No physician at team meeting(north York General Hospital-Community Based ) A comprehensive plan is developed with goals but it s not integrated at this time, which is something we are working towards. We do have the weekly planning meetings and also have a family team meeting for discharge planning. Yes it fits within organization's strategic priorities. (St.John's Hospital - ) Client and family centered care; Inter-Professional practice and collaboration are key initiatives of the organization and of the ilitation program(baycrest- ilitation Program) No physician involvement (North York General Hospital- /low No physician input at team meetings (North York General Hospital- ) Standard # 7 survivors will receive the appropriate intensity and duration of clinically relevant therapies across the care continuum based on individual need and tolerance. Moderate stroke: Survivors of a moderate stroke will receive a minimum of one hour of direct therapy time for each relevant core therapy, with an individualized treatment plan, for a minimum of five days per week, by the interprofessional stroke team based on an individual need and tolerance. Severe stroke: Survivors of a severe stroke who are Ready will receive the frequency and duration of therapy that can be tolerated; the interprofessional team will increase the frequency and duration as tolerance improves to a minimum target of one hour of direct therapy time for each relevant core therapy, with an individualized treatment plan, for a minimum of five days per week, by the interprofessional stroke team based on individual need and tolerance. Standard # Acute Based (high 4 (low Not met Partially met Fully met 0

11 The dedicated stroke or mixed population interprofessional team provides a minimum of minutes of therapy per service as indicated from the following rehab professionals: Table. Standard 7, sub-question regarding Interprofessional Team Therapy Acute Based (high (low yes no yes no yes no yes no yes no Occupational Therapy 0 Physiotherapy 0 0 Speech Language Pathology 3 0 Table 3 - Frequencies of answers to Standard 7 indicator: Admission criteria include stroke clients who require more than one service and were discharged from the following Acute care with FIM tm score > 80 who require home-based stroke rehab stroke rehab and who require communitybased stroke rehab services Acute care and transferred to long-term care and who require community-based stroke rehab services yes no

12 Single Service Typical length of stays varies depending on service offered from one or a few visits to -3 times per week. Single Service - Typical length of stays Not met Interprofessional Team - Typical length of stays is 6- weeks, -3 times per week. Interprofessional team; typical length of stays Not met

13 Where therapy includes OTA/PTA services under the guidance of OT/PT, no more than half of the therapy time is provided by the OTA/PTA. Where therapy include OTA/PTA Acute (high (Low Not met Staffing ratio support the minimum amount of therapy recommended. Staffing ratio Acute (high (low Not met Fully met 3

14 Challenges/Limitations/Fit within organization s strategic priorities While in acute care-answer is yes; can't answer for rehab facilities(north York General Hospital - Community Based ) As previously noted, the MOST program is a stroke self-management program for people living in the community who has now completed their active rehabilitation phase. The program does not offer stroke rehabilitation(baycrest Moving On after MOST) 4

15 THEME 3 - QUALITY CARE STROKE REHABILITATION SHOULD BE DELIVERED IN ALL SETTINGS BY AN INTERPROFESSIONAL TEAM WITH STROKE EXPERTISE. STROKE SURVIVORS SHOULD RECEIVE THE INTENSITY AND DURATION OF STROKE REHABILITATION SERVICES AS CLINICALLY INDICATED. Standard #8 All stroke survivors who would benefit from inpatient stroke rehabilitation will be treated in a stroke rehab unit or geographically defined unit with a stimulating environment. Standard # Acute (high (low Not met Partially met Fully met 5

16 If provided on a mixed unit, a variety of diagnostic population groups are served. A critical mass of 8 beds within the unit is available to support the development and maintenance of clinical expertise among nursing, allied health and medical staff and the acquisition of special equipment/ resources required to treat stroke patients. (On a mixed rehab unit, these beds may serve patients with other types of neurological conditions). If provided on a mixed unit Acute -high tolerance -low tolerance Not met Partially met Fully met Challenges/Limitations/Fit within organization s strategic priorities We are providing a geographically defined unit with stroke specific expertise, however, it is a mixed diagnosis unit that is not optimally stimulating stoke patients(the Scarborough Hospital - Acute Medicine/) Not possible to have all strokes on the one unit, when bed capacity is running so huge (North York General Hospital- Acute stroke) 8 beds not specifically geographically designated; not all stroke cases come to the appropriate unit; environment not always stimulating (North York General Hospital- ) The organization is focused on care of the elderly. The Unit is therefore specialized in the care of the elderly. The admission criteria for the stroke clients to the Baycrest ilitation Unit is 55 and over(baycrest- ilitation Program) 6

17 Standard # 9 Once it is determined that a stroke survivor will benefit from inpatient rehabilitation and once Ready, the stroke survivor will have access to an interprofessional rehabilitation team with expertise in stroke care. Standard # 9 rehabilitation Acute 4 3 (high (low Fully met providers on a mixed unit have expertise in stroke rehab although they may assess /treat a variety of other diagnostic population groups on the unit. providers (high (low Fully met 7

18 In a high tolerance program, the admission criteria are used to identify patients with early FIM tm scores as assessed during st week post onset (i.e. "middle band patients) and for younger stroke patients (i.e. <55 years of age) regardless of stroke severity. (Note: age criteria are used as guidelines rather than applied rigidly to each patient to allow for individual differences in functional status among patients). In a high tolerance program (high (low Fully met Once it is determined that a stroke survivor will benefit from community rehabilitation (i.e. home based or ambulatory) and once ready, the stroke survivor will have access to interprofessional rehabilitation team with expertise in stroke care. 0.8 Standard #9 Community ilitation Based Partially met Fully met 8

19 Challenges/Limitations/Fit within organization s strategic priorities Depends on where the client lives and if the services exist or are accessible in his/her area. (Sunnybrook Health Sciences Centre- Regional Team - North and East GTA ) Standard #0 Post acute care will be delivered using a collaborative practice model. The interprofessional team will consist of a core team with clinical expertise including the stroke survivor and family/caregivers and health care practitioner listed below. Table 4 - The interprofessional team consists of. Acute Based (high (low Yes No Yes No Yes No Yes No Yes No Primary Care Physician Physiatrist and other physician (e.g Hospitalist) ilitation Nurse Nurse Physiotherapist Occupational Therapist Social Worker Speech Language Pathologist Family Facilitator Psychologist

20 Table 5 Access to consultation from Acute Based (high (low yes no yes no yes no yes no yes no Recreational 0 3 N/A 0 N/A N/A therapist Spiritual care provider Clinical dietician Pharmacist Discharge planner Neurologist N/A N/A Geriatrician N/A N/A Psychiatrist N/A N/A Table 6 Service includes consults for Acute Based (high (low yes no yes no yes no yes no yes no Vocational N/A N/A assessment Driving N/A N/A assessment Video fluoroscopic swallowing assessment Orthoses 0 N/A N/A 3 0 Augmentation 0 N/A N/A 3 0 communication Complex seating 0 N/A N/A 3 0 0

21 Table 7 Services include screening for Acute Based (high (low yes no yes no yes no yes no yes no Cognitive function Behavioural issues Depression/Mood Falls Challenges/Limitations/Fit within organization s strategic priorities See check marks to see what we have achieved. Unable to access nurse, rec therapist, more dietician time (currently only 3 days/week), neuro psychologist, discharge planner, vocational therapist and driving assessment (Sunnybrook Health Sciences Centre- General Medicine/Acute) Not having adequate resources OT/PT/OTA; not all stroke cases coming to stroke unit (North York General Hospital - Acute stroke) Again, stroke participants for MOST have completed their active rehabilitation. However, participants are provided with information on a variety of community resources along with problem solving skills and how to access needed information for current needs as well as future needs. The program does not specifically provide links to other services but assists participants in how to find the information they need to self-manage their stroke condition and make the necessary links(baycrest- Moving On after /MOST) The SLP assigned to the program performs Video fluoroscopic swallowing assessment onsite. The SLP and the dietitian attend the dinning room daily for lunch supervision and assess and support patients with swallowing risk or difficulties. A nurse is also on duty at the lunch room to monitor at-risk patients. The neurologist is a core team member. All core team members attend the weekly team conference. The geriatrician is the medical director who attends the weekly team conference and participates in all family conferences. All patients are assessed by the geriatrician. The attending physician makes daily rounds and assesses all newly admitted patients as well as attends the weekly team conference. PT, OT, therapeutic Rec and SLP treatments are delivered on the Unit. patients have access to hydrotherapy in a warm water pool as augmentation to their physiotherapy. Many cultural, spiritual and recreational programs are available to the patients on the unit and within organization. The organization is focused on the elderly and their family, from all aspects of care including the spiritual aspect of the whole person.(baycrest- ilitation Program/high Staffing mix and the services provided fit within the Baycrest strategic priorities. The primary care MD is involved through consultation notes, but the primary MDs are not formally part of our team. Clients are referred out for vocational assessments and driving assessments, though basic

22 screening for driving ability is done within the and Cognition Clinic program.(baycrest- and Cognition Program)

23 Standard # Therapy will include repetitive and intense use of novel tasks that challenge the stroke survivor to acquire necessary skills during functional tasks and activities. The interprofessional team, along with the family/caregiver and volunteer, will promote the practice of skills gained in therapy into the stroke survivor s daily routine and will reinforce increased stroke survivor participation and activity. Standard # Acute Based (high (low Partially met Fully met Patients have the opportunity to participate in as much therapy appropriate to their needs as they are able and willing to tolerate. Patients have the opportunity Acute (high (low Not met Partially met Fully met 3

24 clients receive specialized focused assessment and/or treatment to resolve a functional or psychological issue and to promote re-integration to normal living or to maximize functional level. clients receive specialized focused assessment Partially met Fully met Interventions are time limited. Interventions are time limited Based Partially met Fully met 4

25 Challenges/Limitations/Fit within organization s strategic priorities Limitations due to times constraints, staffing resources and lack of appropriate equipment. No caregivers available with dedicated time for patients to repetitively practice tasks (Sunnybrook Health Sciences Centre- General Medicine/Acute) No formal education program for family/caregivers to reinforce participation + activity (North York General Hospital- Acute stroke) No formal process of sharing information; manpower/resources limited; no formal education for family/caregiver (North York General Hospital- Community Based ) The discussion topics are related to building the necessary self-management skills needed for moving on with life after stroke. The exercise component incorporates functional tasks and activities and prepares the participants to be able to access community based physical activity programs after completing MOST(Baycrest- Moving On after /MOST) Limited resources; no formal education for family/caregivers (North York General Hospital- /high No education program; limited resources (North York General Hospital - /low Sometimes, clients want more treatment than the team can give due to limited resources. (Sunnybrook Health Sciences Centre- Regional Team - North and East GTA/) Limited human resources; no formal education for family/caregivers (North York General Hospital- ) 5

26 Standard #a Interprofessional Team Knowledge and Skills The interprofessional team will have access to stroke rehabilitation education and professional development modules in order to support the standards and other evidence-based practice initiatives. These educational opportunities will be evidence-based, current and user-friendly and will incorporate knowledge translation strategies Standard # a Acute Based (high (low Not met Partially met Fully met Challenges/Limitations/Fit within organization s strategic priorities One education day/year; limited funding; no staff coverage when away; no stroke education within facility (North York General Hospital- Acute stroke) Limited education days (one per year) (North York General Hospital - Community Based ) As applies to Self-Management for stroke (Baycrest- Moving On after MOST/Community) One education day per year (North York General Hospital- /high The team participates in externally available continuing education opportunities e.g. Collaborative, NDT courses etc. as well as attends the monthly interprofessional grand rounds. The team is also expected to present in at least one interprofessional grand round per year to share their knowledge and expertise. Dr. Jon Ween the specialist and researcher at Baycrest engages the team on a monthly basis in case analysis and discussion to develop team member s knowledge and skills on stroke rehab and on neurophysiology (Baycrest- ilitation Program) Limited education days (North York General Hospital - /low 6

27 Education days limited (North York General Hospital- ) Standard #b Patient/Family Education survivors, family/caregivers and volunteers should be provided with information and education at all stages of care across the continuum (prevention, acute care, rehabilitation, community reintegration). Information and education should be interactive, timely, up to date, provided in a variety of languages and formats (written, oral, counselling approach), and specific to stroke survivor and family/caregiver needs. Standard # b Acute Based (high (low Not met Partially met Fully met Table 8 Education should address information about Acute Based (high (low yes no yes no yes no yes no yes no Nature of the stroke Signs and symptoms Impairments and their impact/management Risk factors Planning and decision making

28 Acute Based (high (low yes no yes no yes no yes no yes no Resources Community Support Table 9 specific wellness interventions should include Acute Based (high (low yes no yes no yes no yes no yes no Health education Goal setting Behaviour change principles and practices to promote health and well being of the client Secondary prevention Challenges/Limitations/Fit within organization s strategic priorities We do not achieve stroke specific wellness interventions for health education, goal setting and behaviour change principles and practices to promote health and well being of the client (Sunnybrook Health Sciences Centre- General Medicine/Acute stroke) No formal education programmes (North York General Hospital Acute ) No formal education process; limited resources (North York General Hospital- Community Based ) Limited resources; no formal education process (North York General Hospital- ) Wellness model is fully adopted by the organization. On discharge, the stroke survivor is given a list of choices to adopt a healthy lifestyle e.g. the Wagman Centre is a community recreation centre offering a number of stroke survivor programs including pool exercise, group and individual exercise and music therapy and stroke recovery group. The MOST, which is a self management program for people after a stroke is also available. The hydrotherapy maintenance program is also available for clients who had participated in hydrotherapy during their rehab admission. A number of the discharged stroke survivors return to Baycrest as volunteers and provide support to clinical programs including the programs available for stroke clients.(baycrest- ilitation Program/high no formal stroke education program (North York General Hospital- /low 8

29 Specific recommendations regarding general health concerns and behavior modification are made to the primary MD, however some specific programs (e.g.: smoking cessation) are offered within Baycrest (Baycrest- and Cognition Program/outpatient) No formal education process; limited resources (North York General Hospital- ) 9

30 THEME 4 - ACCESSIBLE CARE ALL STROKE SURVIVORS WHO MIGHT BENEFIT SHOULD HAVE AN OPPORTUNITY TO PARTICIPATE IN REHABILITATION IF CLINICALLY INDICATED. Standard #3 All stroke survivors regardless of where they live will have equitable access to the same standard of care at the appropriate intensity and duration. 0 8 Standard # Based Not met Partially met Fully met Challenges/Limitations/Fit within organization s strategic priorities Admission criteria to rehab facilities causes limitations- i.e. behavioural co morbidities (North York General Hospital- Community Based ) This is not at all achievable as some clients referred to the clinic live in remote areas. If clients can make arrangements for lodging/transportation, then access to services is not restricted because of geographic boundaries. Referrals to local agencies are made where they exist (Baycrest- and Cognition Program/outpatient) Some patients live in areas where there are not enough or any rehab resources (Sunnybrook Health Sciences Centre - Regional Team - North and East GTA/) Criteria for admission to rehab facilities sometimes delays transfer (North York General Hospital- ) Standard #4 30

31 survivors of a moderate or severe stroke who are Ready and have rehabilitation goals will be given an opportunity to participate in inpatient stroke rehabilitation. Standard # Acute (high (low Fully met Challenges/Limitations/Fit within organization s strategic priorities The people with the severe stroke may be admitted to Baycrest's CCC program for long stay low intensity therapy (Baycrest- ilitation Program /high 3

32 Standard #5 Once in a LTC Home, Complex Continuing Care Unit or Alternate Level of Care bed, residents should have access to stroke rehabilitation services as clinically indicated and based on the stroke survivor's goals through ambulatory, outreach or CCAC if it is not available in-house. Standard # Based Inpatinet (low Partially met Fully met Challenges/Limitations/Fit within organization s strategic priorities Met while in acute care + designated ALC (North York General Hospital- Community Based ) Met for ALC patients in acute care (North York General Hospital- /low The services of the and Cognition Clinic are made available where possible, though once the patient is discharged from the program access navigation is not provided by clinic staff to other services (Baycrest- and Cognition Program/outpatient) Some long term care facilities provide rehab some do not (Sunnybrook Health Sciences Centre- Regional Team - North and East GTA) Met while designated ALC in acute care (North York General Hospital- ) 3

33 Standard #6 survivors who are discharged to the community with home- based stroke rehabilitation services will be provided with these services as per available evidence-based guidelines. Standard # Based Fully met Services are provided in the environment that is most appropriate (e.g. client is home-bound; services are focused on community re-engagement, school re-integration or vocational return). Services are provided in the environment that is most appropriate 35% 3 5% 5% 5% Fully met Based 33

34 Challenges/Limitations/Fit within organization s strategic priorities Standard #7 Interprofessional teams will facilitate linkages for stroke survivors and their family/caregivers after discharge to services in the community including: Table 0 After discharge, linked to Physical help Caregiver training and education Psychosocial counselling Acute Based (high (low yes no yes no yes no yes no yes no Table Access to Acute Based (high (low yes no yes no yes no yes no yes no Primary care practitioners Case management or other system navigation service Respite care Educational opportunities 0 Emotional help

35 Acute Based (high (low yes no yes no yes no yes no yes no Wellness Vocational counseling resources Driving safety evaluation Transportation services Peer support groups Community re-integration services Prevention clinic/services Financial support Initiation of appropriate secondary prevention and rehab referral outpatient/community-based rehab as is appropriate. Initiation of appropriate secondary prevention Acute Based 3 (high (low Not met Partially met Fully met 35

36 Challenges/Limitations/Fit within organization s strategic priorities Lack of data base to access information regarding community services/access (North York General Hospital-Acute stroke) No formal education process while in hospital; no formal linkages to community (North York General Hospital-Community Based ) As applicable to stroke self management post rehabilitation phase (Baycrest- Moving On after MOST/community) CCAC referrals (North York General Hospital- /low 36

37 THEME 5 - TIMELY CARE. TIME IS FUNCTION TIMELY ACCESS TO APPROPRIATE AND QUALITY STROKE REHABILITATION SERVICES ARE CRITICAL FOR ACHIEVING THE MAXIMUM GAINS FOR STROKE SURVIVORS. STROKE IS A CHRONIC DISEASE. WITHOUT TIMELY AND APPROPRIATE REHABILITATION, STROKE CAN BECOME A DEBILITATING DISEASE. Standard #8 The wait time from when the stroke survivor is Ready and referred to rehabilitation services until the start of all appropriate rehabilitation services should be no more than: Two business days for inpatient stroke rehabilitation, and Five days for both ambulatory and home-based stroke rehabilitation. Standard # Based (high (low Not met Partially met Fully met Challenges/Limitations/Fit within organization s strategic priorities No control once patients discharged; business days- best case scenario for < 3 weeks; > 3 weeks not met (North York General Hospital - Community Based ) < 3 weeks - best case scenario < days ; no control of home based referrals (North York General Hospital- /high In-patients within two business days with completed applications and appropriate referrals; outpatient wait list of two weeks. Yes it fit (St.John's Hospital- /high Accepted + wait listed; bed not available in timely (North York General Hospital- /low Sometimes we have a wait list of over 5-0 days (Sunnybrook Health Sciences Centre- Regional Team - North and East GTA) 37

38 days best case scenario < 3 weeks rehab; no control care discharged (North York General Hospital- ) 38

39 THEME 6 - SYSTEM PLANNING THE STANDARDS CREATE A FRAMEWORK FOR SYSTEM PLANNING BOTH AT THE REGIONAL LEVEL (I.E., THE SERVICE PROVISION MODEL) AND AT THE PROVINCIAL LEVEL (E.G., USING DATA TO PLAN, COORDINATE, INTEGRATE AND SET PRIORITIES FOR CARE). Standard #9 Each stroke region will have an explicit stroke rehabilitation service provision model in place in order to facilitate optimal and timely access to rehabilitation services. (Please refer to the Service Provision Model that has been attached in the for your reference) Do you use a service provision model? No program/service uses a service provision model. If you do use a model, please indicate which one and if not, why? Uncertain how this applies to the MOST program - Baycrest as a whole is part of a service provision model (Baycrest- Moving On after MOST/community) Standard #0 Clinical and service utilization data will be used to plan, coordinate, integrate and prioritize regional stroke rehabilitation services and ensure equitable access based on patient need. Did you use data for decision- making purposes? Seven out of 4 services/programs answered yes to this question; another two programs answered that they don t use data for decision -making purposes. If you answered no to the above, please explain why. GTA rehab network receives applications referral data-not used as part of the referral process (North York General Hospital- Acute stroke) Decisions are made using utilization data for program planning.(baycrest- and Cognition Program/outpatient) 39

40 Based on the above survey, would you classify your program as an Acute Care Integrated Unit? Would you classify your program as an Acute Care Integrated Unit? Acute (high Yes No Program s top -3 strengths: Comprehensive program Interdisciplinary care provision Early assessment/referral (The Scarborough Hospital- Acute Medicine/) Knowledge and expertise of the staff -Communication of the team on a daily basis -Coordinated care planning (Sunnybrook Health Sciences Centre- General Medicine/Acute stroke) Timely access to diagnosis; nursing team and clinical expertise; strong multidisciplinary team; physician support; high school knowledge, skills, expertise around stroke care (North York General Hospital - Acute stroke) Dedicated knowledge team; timely access to diagnostics (North York General Hospital- Community Based ) Combination of exercise with the self-management approach Goal setting and action plans as a means of moving forward Program improvements based on data and outcome evaluation (Baycrest- Moving On after MOST/community) Dedicated professional rehabilitation team; patient centered care; integrated approach to rehab (St.John's Hospital - ) Strong interprofessional team with representations from all rehab professions and active participation from the attending physician and the Geriatrician. Collaborative team work on management of pain and titration of appropriate level of pain medication. In addition to addressing the physical and functional aspects of stroke recovery, the Program and the specialization on gerontology are both very focused on the cultural and spiritual aspect and its contribution to recovery. Our understanding and specialization on gerontology are added value to the ilitation of the elderly. The organization had full adopted electronic documentation which greatly enhances care and communication among many care providers. Information related to the patients are always available and accessible to all care providers any where they could access the 40

41 electronic system, even when they are not physically on the Unit. Orders could be entered anywhere and results are available when the system is accessed (Baycrest ilitation Program/high Research and evidence-based program with strong ties to other inpatient and outpatient services, delivered by an interprofessional team using a data-based approach.( Baycrest and Cognition Program/outpatient) Interprofessional team Using standardized assessments (Sunnybrook Health Sciences Centre- Regional Team - North and East GTA/outpatient) Program s top -3 challenges: Length of stay (especially for low tolerance/long duration) Complexity of some patients repatriated from regional stroke centre (The Scarborough Hospital - Acute Medicine/) -Limited staffing to meet the rehab levels -Not a stroke specific unit -Competing priorities--the stroke patients, general medicine patients, short stay rehab patients -The stroke "program" is not recognized as a core priority for the hospital (Sunnybrook Health Sciences Centre- General Medicine/Acute ) stroke patients being bed spaced in other area; lack of formal education program; lack of human resources for therapy (North York General Hospital- Acute stroke) Lack of formal education program; limited human resources; all patients not coming to stroke unit (North York General Hospital- Community Based ) Recruitment and marketing (Baycrest- Moving On after MOST/community) Community reintegration-limited resources; video fluoroscopy f/u; lack of neuropsychology (St.John's Hospital- ) Sufficient staffing to meet the complexities and co-morbidities associated with elderly patients. The challenges of balancing client and family wishes to the safety and function capacity of the client to the discharge destination.(baycrest- ilitation Program/high Improving the continuum of care from the inpatient setting to the and Cognition Clinic is a current opportunity for improvement. Coordination of part-time interprofessional staff servicing the clinic to provide the most efficient and seamless care for the client is also a constant challenge. (Baycrest- and Cognition Program/outpatient) wait times client re-assessment community resources for rehab (Sunnybrook Health Sciences Centre- Regional Team - North and East GTA/outpatient) Top initiatives/standards important to address in the next - years: Primary prevention at the family health team level Faster access to rehab beds for low tolerance/long duration (The Scarborough Hospital Acute ) Dedicated stroke unit. To have all stroke patients followed by one medical team.(sunnybrook Health Sciences Centre-General medicine/acute ) integrated formal education plan for stroke clinical pathway (North York General Hospital- Acute stroke) formal education program; designated stroke beds (North York General Hospital Community Based ) 4

42 Integration and coordination at the community level for additional ongoing programs that support physical activity and health behaviour opportunities once rehab is complete Building of selfmanagement and wellness linkages with primary care (Baycrest- Moving On after MOST/community) Standard #0-integrated assessments and care plans, goal setting; Standard #7 community reengagement (St.John's Hospital- /high To continue to measure client satisfaction and to address areas where that would be improved (Baycrest- ilitation Program/high The development of a central intake/triage system within the ambulatory programs would reduce the risk of duplication of services or clients being serviced by a less appropriate clinic within the Organization. (Baycrest- and Cognition Program/outpatient) Increasing community resources for rehab (more outpatient services) Decreasing wait times. (Sunnybrook Health Sciences Centre- Regional Team - North and East GTA) Top initiatives/standards important to address in the next 3-5 years: Retention of neurologist as part of the primary care team vs. hospitalist model (The Scarborough Hospital- Acute Medicine/) There are too many competing priorities. We need to focus priorities and resources to meet those priorities. The stroke "program" is not recognized as a core priority for the hospital. (Sunnybrook Health Sciences Centre- General Medicine/Acute care) increasing HR for intensive therapy (acute);having stroke a hospital priority (North York General Hospital- Acute stroke) Above ongoing (Baycrest- Moving On after MOST/community) Participation in the development and implementation of a regional outcomes driven Quality Assurance program. (Baycrest- and Cognition Program/outpatient) 4