QBP Rehabilitation Planning

Transcription

1 QBP Rehabilitation Planning Achieving Best Practice for Stroke Therapy Intensity October 22, 2015 Welcome! Start by doing what s necessary; then do what s possible; and suddenly you are doing the impossible. Francis of Assisi 1

2 What to expect today Knowledge exchange Research evidence Lived experience Practice-based experience Time to learn from each other and plan together Planning Group Kendra Truant Tazdia Burnett Denise St Louis Linda Dykes Eileen Britt Ellen Richards Joan Ruston-Berge Jennifer Beal Deb Willems Sheila Cook 2

3 Site Visit Recap May 2015 When it comes to Rehab Intensity, where are you on the emotional voyage of change? Denial Embrace Anger Hope Bargaining Acceptance Depression 3

4 What are you feeling hopeful about? Better outcomes for stroke clients Better coordinated, comprehensive, consistent stroke care More team work and opportunities to use skills What are you feeling hopeful about? More concise documentation Tracking will ensure intense treatment Focus on implementing best practice in stroke rehab will spill over to other diagnostic groups Increased awareness of issues frontline staff face; and need for more staff 4

5 What are you concerned about? Therapists Adequate staffing; burnout Therapist time spent on cleaning, portering, etc. Amount of time spent charting and documenting College regulations Limited time/focus on updating skills No feedback to staff about performance; NRS data System issues Not meeting QBP target of 3 hours/day Decreased LOS; pressure to meet discharge date; lack of input into exceptions; complexity of patients Lack of understanding by decision makers What are you concerned about? Models of Care Using a cookie cutter approach; not addressing variability in stroke Rehab intensity trumping clinical reasoning Loss of value for the emotional, social and recreational aspects of recovery Practicing in silos; less collaboration Reducing group work Practicality of seeing patients for shorter, more frequent sessions Patient considerations Non-stroke clients getting less therapy time Patient tolerance; patient compliance; patients are more acute Meeting needs of clients only requiring one therapy 5

6 Priorities for Improvement Frequency Frequency Priorities for Improvement Related to Increasing Rehabilitation Intensity Staffing Resources All Patient Access patient readiness for therapy times competition for limited treatment times Scheduling improve coordination, maximize efficiency and communication provide options to rapidly build tolerance Team Coordination/Processes efficiency of time spent in rounds, meetings appropriate personnel for each task Space & Equipment availability of necessary equipment access to sufficient space Patient Expectations provide culture/expectation of active participation seek patient experience to inform change Documentation builds on work already completed in acute care charting by exception Bluewater, Owen Sound, St Thomas Woodstock, Parkwood (portering) Windsor Chatham, Owen Sound, St Thomas, Bluewater Bluewater, Windsor, Stratford Parkwood Chatham Woodstock Windsor Stratford Staff education build on stroke expertise availability of education in accessible formats 6

7 Hopes for October Workshop Networking, collaboration Better understanding of Rehab Intensity Identify goals; plan for implementation Ideas from others Strategies for achieving targets Compare data/staffing across facilities Individual Activity: Collaboration Central Collaboration Central > Big challenge collaboration is key Who can you collaborate with to improve rehab intensity and improve patient outcomes? Write names/roles on post-it-notes National & International Provincially Across SW Your hospital Stroke Rehab Team 7

8 Patient Experience John Topham Small group activity: Discussion How can our team get better at using feedback about patient experiences to improve patient care? > Worksheet 1 8

9 Break Please return at 1040 Why Does Intensity Matter in Stroke Rehabilitation? Robert Teasell MD FRCPC Professor Phys Med Rehab Western University London. Ontario, Canada 9

10 Brain Reorganization The brain has significant capacity to reorganize itself to recover from loss of function following a stroke Reorganization depends on training or rehabilitation and will not occur spontaneously Brain Reorganization: Use It or Lose It Rehabilitation training (enriched environments with animals) increases brain reorganization with subsequent functional recovery In animal studies key factors promoting recovery include increased activity and a complex, stimulating environment Lack of rehab causes decline in cortical representation and delays recovery 10

11 Mean Barthel What Evidence Do We Have Therapy Intensity Is Important? Frontloading 20 SRU 18 GMU Weeks RCT of 146 middle band strokes to stroke unit (SU) or gen med (GM) unit Median Barthel Index = 4/20 initially in both Stroke Unit - BI = 15 after 6 wks; discharged at 6 wks General Medical Unit - BI = 12 after 12 wks; discharged at 20 wks Kalra et al

12 Mean hrs/pt % D/C Frontloading (Kalra et al. 1994) SRU 80 GMU Weeks Frontloading (Kalra et al. 1994) Amount of Physiotherapy and Occupational Therapy 20 * OT PT 10 0 SRU GMW 12

13 % D/C Mean hrs/pt Mean Barthel Therapy Intensity: Front Loading Kalra et al OT PT * 20 SRU 18 GMU Weeks 10 0 SRU GMW SRU 80 GMU Weeks Role of Intensity of Therapy Post-stroke rehab increases motor reorganization while lack of rehab reduces it; more intensive motor training in animals further increases reorganization Clinically greater therapy intensity improves outcomes; reported for PT, OT, aphasia therapy, treadmill training and U/E function in selected patients (i.e. CIMT) One exception is VECTORS trial (Dromerick et al. 2009); showed high intensity U/E CIMT (6 hrs/day) starting day 10 showed less improvement at 3 mos than less intense Rx; Rationale uncertain not a large trial Dromerick et al. Neurology 2009; 73:

14 Number of Repetitions in the Upper Extremity No study has systematically determined a critical threshold of rehab intensity needed to obtain a benefit (MacLellan et al 2011) Research involves thousands of repetitions EXCITE trial involved 196 hours of therapy per patient Threshold not reached, recovery affected arm less; patients develop compensatory movements (Han et al 2008; Schweighofer et al 2009) Lang et al. (2007) found practice of task-specific, functional U/E movements occurred in half of U/E rehab sessions: Average number of reps = 32 Technology (video gaming, robotics) may be necessary to achieve the maximum number of reps (Saposnik et al. 2010) MacLellan et al. NeuroRehab and Neural Repair 2011; 25(8): Han et al. PLoS Comput Biol 2008; 4e Schweighofer et al. Phys Ther 2009; 89: Lang et al. Arch Phys Med Rehabil 2009: 90: Saposnik et al. Stroke 2010; 41(7): Inactive and Alone In a therapeutic day >50% time in bed 28% sitting out of bed 13% in therapeutic activities Alone for 60% of the time Contrary to the evidence that increased activity and environmental stimulation is important to neurological recovery Bernhardt et al. Stroke 2004; 35:

15 Recommendations Regarding Inpatient Therapy Intensity Following Acute Stroke International recommendations made regarding therapy intensity variable 3 guidelines recommended daily minimum amounts of therapy, ranging from 45 to 60 minutes per day each of physical therapy (PT) and occupational therapy (OT) (or all relevant core therapies) 3 guidelines made nonspecific statements indicating that increased intensity of therapy was either recommended or in the case of one not recommended Foley et al. Topics Stroke Rehabil 2012; 19(2): ii. Best Practice Recommendation 5.3 Delivery of Inpatient Stroke Rehabilitation Patients should receive a minimum of three hours of direct taskspecific therapy, five days a week, delivered by the inter-professional team [Evidence Level C]. Average therapy hours of direct PT, OT and SLP 5 days per week is about hours per day; most rehabilitation units do not supply 3 hours of therapy per day Parkwood Hospital (Foley et al. 2012) 123 pts from May - Oct 2009 workload measurement Infomed data for PT, OT and SLP and associated therapy aids measured A multivariable model to predict FIM gains achieved during hospital stay was also developed. The model explained 34% of the variance in FIM gain; total amount of therapy provided by OT and PT combined emerged as a significant predictor; days from stroke onset and admission FIM scores were also significant predictors. Foley et al. Disability and Rehabilitation Intensity makes a difference 2012; 34(25):

16 Three Issues in Providing Intensity Resources Innovation Accountability Ontario Resources Facilities were asked about staffing levels for 7 rehabilitation professions Estimated staffing levels were provided as a ratio of rehab beds per FTE to reflect the average case-load experienced by research staff across each region Only facilities for which complete bed and FTE information were available were used in the calculations Slow stream or LTLD beds not included in analysis Number of Rehab Beds per FTE in LHINs (median) Physiotherapy (10.0) Occupational Therapy Speech Language Pathology (11.7) (33.3) Social Work (30.0) PT/OT Assistant (13.6) Dietician (227.3) *NA in 6 LHINs Recreational Therapist (63.7) **NA in 2 LHINs Meyer M et al. The Impact of Moving to Stroke Rehabilitation Best Practices in Ontario. Ontario Stroke Network 2012, 66 pages. 16

17 Ontario Hrs of Therapy Per Day Approximately how many hours of therapy a day were provided for PT, OT and SLP? Of 54 facilities surveyed, only 2 reported officially documented number of hours of therapy provided to patients Estimated therapy per patient ranged from 20 minutes to 4 hours per day 17 rehab units had SLP available on a consult basis only Meyer M et al. The Impact of Moving to Stroke Rehabilitation Best Practices in Ontario. Ontario Stroke Network 2012, 66 pages. Replacement of Therapists in Sickness and Holidays 45% of rehabilitation units had access to resources to cover therapists when they were sick Only 28% indicated they were successful in replacing a sick therapist 80% of the time 56% reported access to adequate resources for therapist replacement during holidays and extended sick leaves 24% reported availability of some form of weekend therapy Resources for Stroke Rehab in Ontario Therapist to patient ratios are low Limited documentation of therapy time spent with patient Therapists are not consistently replaced when sick or on holidays Meyer M et al. The Impact of Moving to Stroke Rehabilitation Best Practices in Ontario. Ontario Stroke Network 2012, 66 pages. 17

18 Innovation (Doing Things Differently) Therapy is Cheap; Length of Stay is Not Core Therapies of PT, OT and SLP are most sensitive to intensity Only 25% of total hospital budget in subacute rehab is spent on core therapies Average length of stay is about 35 days Limited weekend or evening therapies Need for Innovation: Using Resources More Efficiently Right-size staff numbers and standardize therapy intensity Establish better accountabilities for intensity Standardize and simplify assessments Simplify and tighten charting Reduce non-therapeutic activities Utilize Weekend and Group Therapy Explore Use of Technologies (i.e Robotics, Gaming) Intensify Outpatient Therapy Rehab Therapies Physiotherapy Occup. Therapy Program and Interdisciplinary Team Speech Therapy Nursing Current interdisciplinary stroke rehab team concept developed in the s Very discipline-specific No longer as relevant rigid, expensive, inefficient 18

19 Program and Transdisciplinary Team Physiotherapy Occup. Therapy Rehab Therapies Rehab Therapists Recreational Therapy Nurse Assistants Speech Therapy Nursing Increasing therapy aids and volunteers Large influx of therapy aids or rehab aids (cross between therapy and nursing aids) The lines between the therapies becoming blurred and how rehabilitation is done redefined Rehab becoming less discipline specific Accountability Collaborative Evaluation of Rehabilitation in Stroke Across Europe (CERISE) Trial Study compared motor and functional recovery after stroke between 4 European Rehab Centers Gross motor and functional recovery was better in Swiss and German than UK center with Belgian center in middle Time sampling study showed avg. daily direct therapy time of 60 min in UK, 120 min in Belgian, 140 min in German and 166 min in Swiss centers Differences in therapy time not attributed to differences in patient/staff ratio (similar staffing) De Wit et al. Stroke 2007:38:

20 Average daily direct therapy time Hrs T herapy per day UK B elgium S witzerland G ermany Hrs Therapy per day De Wit et al. Stroke 2007:38: European CERISE Trial No differences were found in the content of physiotherapy and occupational therapy In German and Swiss centers, the rehabilitation programs were strictly timed (therapists had less freedom), while in UK and Belgian centers they were organized on an ad hoc basis (therapists had more freedom to decide)! More formal management in the German center may have resulted in the most efficient use of human resources, which may have resulted in more therapy time for the patients De Wit et al. Stroke 2007:38:

21 Intensity: The 3 Hour Rule In Canada we struggle to provide adequate therapy The 3 hour rule is an American invention Not from the insurers it is from Medicare States that all rehabilitation patients should get 3 hours of therapy per day of patienttherapist direct or face time In Ontario/Canada the estimate is the average rehabilitation patient gets 1-2 hours of direct patienttherapist time To ensure compliance it is tied to funding PSROP Centers (Brendan NIH) U.S. Inpatient Stroke Rehabilitation is driven by Medicare which expects: 1. Participation ( the 3 Hour Rule ) 2. Progress (FIM Gain of 1-1.5/day) 3. Expedited Discharge Home or to SNF if progress is too slow or family unwilling/unable to take home Therapist must record face-to-face interactions with pt in 15 min increments Manager responsible at end of day to ensure patient received their full 3 hrs of therapy Any missed therapy must have a strong medical justification documented by MD and therapist Failure to deliver enough time means loss of payment Small group discussion How can our team use this evidence to improve patient care? > Worksheet 2 21

22 Current State Data 22

23 SWO Rehab Intensity Q1 2015/16 HDGH 27% BWH 13% STEGH 14% SJHC WGH 22% 28% Therapist Time Assistant Time HPHA 17% GBHS 27% HOUR Rehabilitation Time in Minutes LOS by RPG for 2014/15 HDGH CKHA BWH SJHC QBP LOS Targets Rehabilitation Length of Stay in Days 23

24 LOS by RPG for 2014/15 STEGH WGH HPHA GBHS QBP LOS Targets Rehabilitation Length of Stay in Days LOS by RPG for Q1 2015/16 HDGH CKHA BWH SJHC QBP LOS Targets Rehabilitation Length of Stay in Days 24

25 LOS by RPG for Q1 2015/16 STEGH WGH HPHA GBHS QBP LOS Targets Rehabilitation Length of Stay in Days Make Quality Improvement Principles Real: Small group activity Principle Work together to solve problems Involve those closest to the work Keep patients experience and needs front and centre Focus on improving processes, systems and tools (rather than blaming individual performance) Always look for ways to get even better. Learn from experiences. Use data to inform decisions How well do we do this now? How could we get even better 25

26 Knowledge Exchange > Use Worksheet 4 to Track Examples and Ideas of QI principles put into action REHAB INTENSITY Strategies to get there October 22,

27 OBJECTIVES Understand the Grand River Hospital Inpatient Rehabilitation Unit Review the catalyst for change, including Waterloo Wellington stroke system changes Outline quality initiatives implemented at Grand River Hospital Inpatient Rehabilitation Discuss strategies to increase rehabilitation intensity Review data demonstrating outcomes of change Discuss challenges encountered INPATIENT REHABILITATION UNIT 33 beds 18 stroke beds, 15 mixed rehab beds Geographically separated on two courts Medical coverage with 2 family physicians 2 days per week, 3 days per week 4 OT s, 4 PT s, 3 TA s, 1 SLP, 0.6 CDA, 0.6 SW, 0.4 REC, RD 27

28 BEFORE AND AFTER Prior to OT s, 3 PT s, 2 TA s No OT/PT teams Ratio 1:11 for all patients All staff attend MDT Discharge dates established based on team discussion Communication with family as needed After OT s, 4 PT s, 3 TA s OT/PT therapy teams Stroke 1:6, Mixed 1:15 One team member attends MDT for group Discharge dates established using RPG and QBP targets Discharge letters/family meeting within 7 days QUALITY INITIATIVES Quality Council Model of Care Group Programming Discharge Planning 28

29 MODEL OF CARE Implemented in 2013 Integration of therapy staff into morning care routine Nursing and therapy communication OT s and TA s working PT s working OR ADL assessment/practice Transfers/ambulation Assistance in dining room with containers and U/E tasks MONDAY TUESDAY WED. THURSDAY FRIDAY SATURDAY SUNDAY ADL S ADL S ADL S ADL S ADL S ADL S ADL S TNSF/A MB TNSF/A MB TNSF/A MB TNSF/A MB TNSF/A MB TNSF/A MB TNSF/A MB ADMIN ADMIN ADMIN ADMIN ADMIN ADMIN ADMIN BULLET RDS PT CARE BULLET RDS PT CARE ADMIN ADMIN BULLET RDS PT CARE MDT PT CARE MDT PT CARE BULLET RDS PT CARE BULLET RDS PT CARE LUNCH LUNCH LUNCH LUNCH LUNCH LUNCH LUNCH 29

30 GROUP PROGRAMMING Sit < - > Stand group GRASP group L/E group (seated and standing) U/E group Aerobic training group Meeting needs of all patient groups Goal: increased goal directed therapy, increased patient activity throughout the day 30

31 DISCHARGE PLANNING Bullet Rounds Multidisciplinary Team Rounds Primary Contact Family meetings Discharge letters Community Stroke Program 31

32 OUTCOMES Median number of days between stroke (excluding TIA) onset and admission to stroke inpatient rehabilitation (RCG-1 and RCG-2). Target 6 GRH 11/12 GRH 12/13 GRH 13/14 GRH Q1 GRH Q2 GRH Q3 Q4 32

33 Proportion of inpatient stroke rehabilitation patients achieving RPG active length of stay Target 73.1% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% GRH 11/12 GRH 12/13 GRH 13/14 GRH Q1 GRH Q2 GRH Q3 GRH Q4 33

34 Median FIM Efficiency for moderate stroke in inpatient rehabilitation (RCG-1). WWLHIN 12/ Target GRH 11/12GRH 12/13GRH 13/14GRH Q1 GRH Q2 GRH Q3 Q4 CHALLENGES Roles and responsibilities in morning care (for therapy staff and nursing) FIM documentation Staffing (part time availability) Staff from other areas not comfortable providing care on unit 34

35 QUESTIONS Team Huddle What did you hear that was interesting, exciting and/or practical? 35

36 Lunch Please return at 1245 Knowledge Exchange Fair Snappy Overviews Visit Displays 36

37 A Lean Approach to Maximizing Stroke Rehab Intensity Neenah Navasero, Stefan Pagliuso, Sarah Rose, Brenda St. Amant, Gorana Zubic Presentation Overview Goal of the Project Challenge/Opportunity Quality Improvement Initiatives Results/Impact Lessons Learned/Survey Results 37

38 Goal of the Project In trying to achieve maximal stroke rehab intensity, this project undertook a Lean Processing approach to maximizing physiotherapy intensity being delivered to persons significantly affected by stroke Challenge/opportunity 2 West/2 East at St. Peter s Hospital is a Restorative Care unit AFIM admission score between Approximately 50% stroke patients on the unit Opportunity to look at efficiencies to maximize rehab intensity for persons with stroke 38

39 Lean Six Sigma A set of principles, concepts, and techniques designed for a relentless pursuit in the elimination of waste. Value Stream Mapping and Spaghetti Diagram 39

40 Fishbone Diagram and Pareto Analysis Physical Gym Environment Removal of unnecessary equipment Reorganization New equipment Application Review Process Assigned schedule Inclusion of OTs Referral Expectations 1-pager for referral sources Stakeholder breakfast Patient Transport Volunteer transport Scheduling Changes Reconfiguration of scheduled gym times Projects 40

41 Participant Survey Results Statement Average Level of Agreement (1-5) Process Using a lean process to find opportunities for improvement was effective Mapping exercises were effective 4.5 Spaghetti Diagram was effective 4 Fishbone was effective 4.5 Pareto Analysis was effective 4.75 Participant Survey Results Statement Average Level of Agreement (1-5) Results Modifying gym space increased efficiency 4 Modifying gym space increased safety 4.75 Application Review Process changes created more available time to spend with patients Information 1-pagers have created realistic expectations in patients and families Patient/gym scheduling changes allowed for more effective treatment time spent with patients Volunteers assisting with patient transport has increased amount of available treatment time

42 Participant Survey Statement Average Level of Agreement (1-5) Recommendations I would recommend that team looking for opportunities for improvement to achieve a specific goal utilize the Lean Methodology as an effective means of achieving their goal 4.75 Conclusion Taking a Lean Processing approach to maximizing physiotherapy intensity for persons with stroke at St. Peter s Hospital created an effective way to evaluate the current state of a program and develop projects to create a more efficient future state maximizing therapists time spent with patients admitted with stroke. 42

43 Contact Info Gorana Zubic Physiotherapist Hamilton Health Sciences Stefan Pagliuso CS Regional Rehabilitation and Community Coordinator Project Rehab Intensity 86 43

44 Project REHAB Intensity Background: Best practice for stroke care is to provide 3 hours of direct task-specific therapy per patient per day. GOAL: Bridge the gap between current practice and stroke BP guidelines for rehab intensity. What did we do: Identified a significant gap between stroke best practice and actual delivered therapeutic intensity. OTA/PTA/CDA managed assigned caseload of stroke patients. Utilized PDSA model to improve rehab intensity. Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 87 Impact Time Before Therapy 1000 PTA/PT co-treat 30 in PT gym 1100 SLP 30 in pt. room 1300 OT 30 in OT gym Total time = minutes Time After Therapy 0900 OTA 30 ADL in pt. room 1000 PTA 30 in PT gym 1100 SLP/CDA 60 in pt. room 1300 OT 30 in OT gym 1400 PT 30 in PT gym Total time = 180 minutes Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 88 44

45 Food For Thought Lessons PDSA effective model for a QI initiative Not top down driven START SMALL!! Challenges Engaging all staff Scheduling issues Patient fatigue Advice Find Champions Get support from your stroke coordinator and manager Change what you are doing if it is not working!! Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 89 Contact Sarah Alexander, SLP(Reg)caslpo. - sarah.alexander@trilliumhealthpartners.ca April Scanlon, OTA/PTA - april.scanlon@trilliumhealthpartners.ca Betty Vukusic, PT- betty.vukusic@trilliumhealthpartners.ca Credit Valley Hospital 2200 Eglinton Avenue West, Mississauga Mississauga Hospital 100 Queensway West, Mississauga Queensway Health Centre 150 Sherway Drive, Toronto 90 45

46 Rehab Tracking Board Our Goals Automatically populate admission and discharge of patients from Cerner Large, colourful and highly visible for patients, staff and families (provide a road map) Provide patient safety info isolation, falls risk Able to schedule therapy appointments from any staff s computer View the tracking board from any computer internet based Fluid refreshes and updates continually 46

47 The Positives Visual view of the patient day therapy and other appointments Nursing can schedule DI or patient out of building, therapy can be scheduled around it Both groups and individual therapy can be booked Colour blending can be used to show when 2 disciplines are working together Both one time or reoccurring appts can be booked The Positives Easy to look at # hours of therapy pt is scheduled for over the day Source of truth (quick glance) to know where the patient is Increase collaboration between therapists planned around patient s day and care 47

48 Challenges All Rehab staff (Allied/Key Nursing Staff) need to be scheduled for initial training (4 to 6 hours) Training now by Allied Health Secretary Scheduling takes upfront time by Rehab Staff Schedule/Board must be updated whenever a change is made to remain accurate Not all Rehab therapy staff work on Rehab exclusively (some in other sites) so must log in for visual Not all Rehab staff work each day Rehab Tracking Board G.ACTI VITIES G.ADL G.BAL G.FIT G.RECR EATION ONLY G.STRO KESUP PORT NURSIN G OT PT RD RECRE ATION SPEEC H STROK EED 48

49 Integrated Stroke Unit Stratford General Hospital Goal Enhance the patient experience Optimize therapy time by improving patient availability and therapy staff activities Value Stream Map of a patient s typical day Created a day in the life outline for therapy staff Improvement initiatives identified EXCEPTIONAL PEOPLE, EXCEPTIONAL CARE 49

50 Changes/outcomes Dedicated PSW time to the ISU beds in the morning Bathing Project: patient s choice (am, pm, evening) Adjusted breakfast tray delivery time Adjusted therapy staff schedules Afternoon therapy available Rounds times changed: frequency and time of day Communication strategies bedside & schedule boards Impact and Lessons Impact: Patients routinely ready for scheduled therapy Breakfast taken before therapy Increased patient engagement Increased staff collaboration and satisfaction Lessons: Involve the whole team in process improvement Ensure the patient is represented i.e. UAC or Collaborative Care Planning Team Change the solution if it s not working 50

51 Contact Info Bonita Thompson Manager Inpatient Medicine/Integrated Stroke Unit and Medicine Clinics, Stratford General Hospital HPHA , Ext 2706 Ellen Richards Manager, District Stroke Centre Huron Perth Healthcare Alliance , Ext 2298 Bluewater Health Sonya Maitland 51

52 Parkwood Institute 7 Day Admissions and Therapy Eileen Britt CARING FOR THE BODY, MIND & SPIRIT SINCE 1869 Goal To implement weekend admissions and 7 day therapy for June 6,2015 Opportunity To align ourselves with QBP standards, sustain best practices, enhance patient outcomes, improve our therapy intensity measures and systematically support our acute care partners with patient flow What We ve Done to Date Completed current and future state maps for weekend admissions with discipline specific detail The process for Friday team reviews of potential weekend admissions were developed and refined Trial admission in partnership with acute care collaborative and joint learning as one system 7 Day therapy consisting of core therapies of PT, OT, SLP and OT/PTA Several iterations of discipline schedules union and non-union A number of models have been experienced to date in order to determine stroke therapy expert provider group balanced with frequency of weekends, continuity of care, workflow and communication handoffs Workload measurement and therapy intensity capture- separate systems currently with plans to use Infomed to provide both. To date, statistics have been captured manually 52

53 Impact Positive outcomes with weekend admissions: Access to rehab beds for acute care has improved LOS targets are more achievable without lost weekend days QBP standards for transitioning are more likely to be met and meets the 7 days/week admission standard A weekend checklist was created Outcomes for 7 Day Therapy Meet QBP standard for minimum of therapy 6 days/week Assist with improving our therapy intensity measures with current resources Supporting the achievement of QBP LOS targets Improving patient outcomes FIM Efficiency Lessons learned Engage staff early and often Investigate other sites and learn from their experience Determine and uphold the established principles- helps to guide future decisions/dialogues Communicate and listen- mini PDSA cycles with each component Contact Eileen Britt ext eileen.britt@sjhc.london.on.ca CARING FOR THE BODY, MIND & SPIRIT SINCE

54 INCREASING REHAB INTENSITY Approaching from many angles Resources Documentation Process WEEKENDS Full day coverage Saturday and Sunday 1OT,1OTA, 1PT,1PTA over 60 mixed bed unit FIMs Customized and changed location of forms to ease completion by Allied health HOLIDAYS add extra therapist one of the weekend days of a holiday weekend INCREASED REHAB INTENSITY DOCUMENTATION Review and streamline required forms charts travel with patients to therapy SCHEDULING Daily resource huddles between therapists GROUPS specific task orientated ; utilize with non stroke population; more focused therapy ROUNDS Reviewing what needs to be discussed and who should be there 54

55 Managing Change Weekly huddles provide support, feedback, acknowledge successes Evidence from outside the organization that demonstrates that change is required Create expectations, don t allow for general statements Rehab Intensity: Weekends and Staff Complement Inter-professional Rehab Team Presented by Kim de Haan, Manager of Therapy Services kdehaan@ckha.on.ca October 22,

56 Goals and Opportunity To increase the number of face to face therapy minutes per stroke survivor on the rehab unit, with a target of 3.0 hours/day, 6 to 7 days/week To adhere to the 33% guideline for maximum assistance time within the target minutes To examine current practice and creatively enhance current routines What we did Added SLP to rehab unit weekend coverage. OT, PT, SLP and TR already there Changed structure of weekend scheduling SLP complement: use of Communicative Disorders Assistant s time on rehab unit and in Transitional Stroke Program 56

57 Outcomes and Impact Stroke survivors have access to all therapies 6 to 7 days/week Impact on patients with non-stroke diagnoses Some of the group work and inter-professional patient activities were put on hold Weekends are more structured, but still working on stimulating environment Data Collection Worked with IS to have therapy minutes imbedded in patient electronic chart New OTA/PTA build, working on CDA build Rehab assessor inputs minutes manually and pulling end results is a work in progress Still working toward target for minutes, however, the assistant complement is at 20 to 30% (high level analysis) 57

58 Lessons learned Three hours/day, 7 days/week can be challenging for elderly and acutely recovering Clinical judgement key to treatment decisions Activities that were set aside should be revisited Data collection is multi-faceted and a work in progress Communication Tools Margo Collver 58

59 Priorities for Improvement Scheduling Team Processes Patient Family Expectations were all identified as areas for improvement Tools for Patients/Families Family Rehab Agreement Outlines expectations for the family Discharge Preparation Checklist Self management tool for patients Patient Information Stroke Rehab Describes concepts of neuroplasticity Your Stroke Journey A guide for people living with stroke Community Re-engagement Cue to Action Trigger Tool A question guide to help patients think about their needs 59

60 Advocating for Change Supporting Your Change Efforts Rehabilitative Care Alliance Ontario-wide collaborative Works with stakeholders to standardize rehabilitative care. Funded by all 14 LHINs, the Alliance aims to: Improve long term clinical outcomes for Ontarians Increase community capacity So people have access to rehabilitative care when and where they need it

61 Presentation Toolkits Definitions Presentation Toolkit; Definitions FAQs Capacity Planning and System Evaluation Presentation Toolkit Frail Senior/Medically Complex Presentation Toolkit Outpatient/Ambulatory Presentation Toolkit Planning Considerations for Re-Classification of Rehab/CCC Beds Presentation Toolkit Definitions Framework Rehabilitation All patients who have experienced sudden onset, life-altering disability (e.g. SCI, ABI, stroke, amputation, multiple traumas) with an expected trajectory of recovery/progression should be considered. To accommodate differing levels of tolerance among patients on admission and increases in tolerance during the inpatient stay, the intensity of rehab may vary from low to high intensity (from at least minutes of therapy 3x per day to 3 hours per day) up to 7 days per week

62 Ontario Stroke Report Card: Southwestern Ontario 2013/14 Indicator #11: Proportion of acute stroke patients (excluding TIA) discharged to inpatient rehabilitation Ontario Average: 34.2% Access in Essex, Middlesex and Oxford Counties is below provincial average MOH Health System Funding Reform Hospitals, Community Care Access Centres and Long Term Care are the first sectors incorporated into the funding strategy Health System Funding Reform Patient-Based Funding is based on clinical clusters that reflect an individual s disease, diagnosis, treatment and acuity Patient-Based Funding (70%) Global (30%) Patient-Based Funding will include HBAM and Quality- Based Procedures Health Based Allocation Model (40%) Quality-Based Procedures (30%) (N.B. 40% and 30% noted is hospital specific; will be different for other sectors) HBAM is a made in Ontario funding model that distributes allocations to organizations in accordance with population needs and their ability to provide cost-effective care. Quality Based Procedures (QBPs) are clusters of patients with clinically related diagnoses or treatments that have been identified by an evidence-based framework as providing opportunity for process improvements, clinical redesign, improved patient outcomes, enhanced patient experience and potential cost savings 62

63 QBP: Quality Based Procedures Clinical Handbook for Stroke (Acute and Postacute) released February 2015 Secondary Prevention Acute Care Inpatient Rehabilitation Community Assessment and Treatment Cross Continuum Processes Recommendations Module 4: Admission to Inpatient Rehabilitation Recommended Practices The interprofessional team should consist of physiatrists, other physicians with expertise/core training in stroke rehabilitation, OT, PT, SLP, RNs, SW, dietitians. Additionally recreation therapists, psychologists, vocational therapists, educational therapists and rehabilitation therapy assistants Recommended staffing ratios for inpatient rehabilitation are: PT/OT: 1 each per 6 inpatient beds SLP: 1 :12 63

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65 Rehabilitation Intensity Webcast You can access the webcast: Every Minute Counts: Stroke Rehabilitation Intensity Presented by: Beth Linkewich Available on the OTN website. Go to webcast.otn.ca click on Public Archived Events, and in the search window plug in the Event #: New webcasts coming: November 18 th January 13 th 65

66 Motor Learning Provincial Stroke Rounds: Wednesday November 4 th Dr. Kara Patterson from the University of Toronto Motor Learning and its Application to Stroke Rehabilitation 1. Define and describe motor learning and the factors that influence motor learning. 2. Identify differences in motor learning between healthy adults and individuals with neurological conditions. 3. Apply concepts related to motor learning to neurorehabilitation. Connect what the evidence says about motor learning to therapy intensity in stroke rehabilitation Team Action Planning Guide Work your way through the guide 15 minutes left make sure you have a Next Steps Action Plan Each team give Jenn last 2 pages for photocopying and you will get it back 66

67 Action Planning: Next Steps Follow-up and support today s action plans Education Planning: Are there needs related to this work? Connecting you with others: Sharing resources within our region and province Creating resources: Are there resources needed that everyone would benefit from? e.g. Family Rehab Agreement Wrap-Up Paula Gilmore Regional Director Southwestern Ontario Stroke Network 67

68 Evaluation Please complete the evaluation and leave it on the table. We really pay attention to your feedback. Safe travels! 68