*Note: Eligibility Criteria for Community-Based Rehabilitative Care Note:

Transcription

1 Overview f the Definitins Framewrk fr Rehabilitative Care Backgrund: The mandate f the Definitins Task Grup is t develp standardized definitins that describe rehabilitative care resurces acrss the cntinuum, including a system-wide Assess and Restre apprach. * The first phase f this wrk fcused n the develpment f the Definitins Framewrk fr Bedded Levels f Rehabilitative Care. The secnd phase has fcused n the develpment f standardized definitins fr cmmunitybased levels f rehabilitative care. These framewrks tgether serve as fundatinal dcuments that define (1) the levels f rehabilitative care acrss the cntinuum and (2) the recmmended standard cmpnents and human resurces within each level f rehabilitative care. While there is recgnitin that the framewrk is nt ppulatin-specific and that the specialized tertiary services prvided by sme Health Service Prvider rganizatins are beynd the resurce threshlds described within the framewrk, the framewrk can be used by LHINs as part f a capacity planning prcess t evaluate rehabilitative care resurces within the cntext f specific patient and lcal/reginal prgramming needs. This wrk has been infrmed by cnsultatins with rehabilitative care prviders acrss the prvince and natinally as well as an extensive review f the literature, including rehabilitatin prgrams/centres in Canada and elsewhere. 1 The bjectives in develping a prvincial Definitins Framewrk are t: Establish prvincial standards fr rehabilitative levels f care acrss the cntinuum f care Prvide clarity fr patients, families and referring prfessinals n the fcus and clinical cmpnents f rehabilitative care prgrams Prvide a fundatin t supprt system and lcal capacity planning thrugh a cmmn understanding f rehabilitative care services The fllwing principles and definitin f rehabilitative care underpin the Definitins Framewrk: Slutins develped by the Definitins Task Grup will: be develped frm the patient s/client s perspective maximize resurce utilizatin standardize and streamline system prcesses (e.g. eligibility, data cllectin) Definitin f rehabilitative care: 2 It is delivered in hmes, cmmunity based lcatins, lng term care hmes and hspitals. Peple may require rehabilitative care as a result f illness, injury, lifelng disability, chrnic disease, r degenerative cnditin. It incrprates a brad range f interventins that address ne r mre f medical/clinical care needs, therapeutic needs, and/r psych-scial needs. The desired utcmes f rehabilitative care will include ne r mre f maintenance r sustaining f functinality 3, restratin f functinality and/r develpment f adaptive capacity Family/significant thers are recgnized as key t enabling patient/client functin and attainment f gals and are invlved thrughut the rehabilitative care prcess: Families/caregivers, with patient/client cnsent, are included in discussins arund key treatment decisins Families (and patients/clients) are encuraged t participate in team meetings Gals and plans are develped frm the patient s perspective and in cncert with families/caregivers, with patient/client cnsent. * An Assess and Restre apprach refers t Assess and Restre interventins that are prvided t a defined ppulatin f high-risk, frail senirs wh have experienced a recent lss f functinal ability fllwing a medical event r decline in health; are at high risk fr imminent hspitalizatin r admissin int a lng-stay Lng-Term Care (LTC) hme bed as a result f that functinal lss; and wh have restrative ptential, i.e., they have the ptential t regain that functinal lss s that they are n lnger at high risk. These interventins are delivered within and acrss a range f existing prgrams and levels f care, including but nt limited t the bedded levels f rehabilitative care described in this framewrk. Cmmunity-Based Rehabilitative Levels f Care / Final / March 2015 Page 1

2 Definitins Framewrk fr Cmmunity Based Levels f Rehabilitative Care The Definitins Framewrk fr Cmmunity-Based Levels f Rehabilitative Care represents the secnd phase f the Definitins initiative and has been drafted with input frm cmmittee members f the Definitins Task and Advisry Grups and the LHIN Leads/Health Service Prviders Advisry Grup, each f which include medical, clinical and administrative stakehlders frm acrss rganizatins and LHINs. The bjectives in develping a Definitins Framewrk fr Cmmunity-Based Levels f Rehabilitative Care are t supprt: Clarity fr patients/clients, families and referring prfessinals n the cmmunity-based levels f rehabilitative care thrugh definitins fr each level that describe gals fr levels f care; target ppulatins; medical and healthcare prfessinal resurces; and the verall fcus and underlying principles f therapy services prvided in the cmmunity Apprpriate/efficient use f rehabilitative care system resurces thrugh the descriptin f resurces within each level f cmmunity based rehabilitative care An understanding f current state resurces t infrm capacity planning The scpe f the definitins within this framewrk includes publicly-funded rehabilitative care prgrams (i.e. LHIN r MOHLTC funded) prvided by r under the supervisin f regulated health prfessinals with a primary rehabilitative care fcus t imprve functin and maintain/prevent functinal decline.* *Nte: While wellness fcused health prmtin/preventin prgrams that are nt prvided by r supervised under regulated health prfessinals are beynd the scpe f the Definitins Framewrk fr Cmmunity Levels f Rehabilitative Care, it is acknwledged that such prgrams play an imprtant rle in the system by prmting verall health and supprting patients reintegratin int the cmmunity. Examples f these prgrams include: Grup exercise; wellness prmtin classes; swimming; walk-fit; yga; Tai-Chi; Pilates; peer supprt and friendly visiting prgrams. Eligibility Criteria fr Cmmunity-Based Rehabilitative Care The cmmunity-based levels f rehabilitative care within this framewrk are t be applied t patients/clients wh meet the fllwing eligibility criteria: The patient/client has restrative ptential*, (i.e. There is reasn t believe, based n clinical assessment and expertise and evidence in the literature where available, that the patient's/client s cnditin is likely t underg functinal imprvement and benefit frm rehabilitative care) r s/he requires rehabilitative care t prevent functinal decline and The patient/client is medically stable enugh such that s/he is able t participate in and benefit frm rehabilitative care (i.e., carry-ver fr learning) within the cntext f his/her specific functinal gals; and The patient/client has identified gals that are specific, measurable, realistic and timely. *Restrative Ptential Restrative Ptential means that there is reasn t believe (based n clinical assessment and expertise and evidence in the literature where available) that the patient's/client s cnditin is likely t underg functinal imprvement and benefit frm rehabilitative care. The degree f restrative ptential and benefit frm the rehabilitative care shuld take int cnsideratin the patient s/client s: Premrbid level f functining Medical diagnsis/prgnsis and c-mrbidities (i.e., is there a maximum level f functining that can be expected wing t the medical diagnsis /prgnsis?) Ability t participate in and benefit frm rehabilitative care within the cntext f the patient s/client s specific functinal gals and directin f care needs Nte: Determinatin f whether a patient/client has restrative ptential includes cnsideratin f all three f the abve factrs. Cgnitive impairment, depressin and delirium shuld nt be used in islatin t influence a determinatin f restrative ptential. Cmmunity-Based Rehabilitative Levels f Care / Final / March 2015 Page 2

3 Part A: Determine which level f cmmunitybased rehabilitative care wuld meet the needs f the patient/client Patient CONCEPTUAL DEFINITIONS FRAMEWORK FOR COMMUNITY LEVELS OF REHABILITATIVE CARE (Draft) These definitins pertain t publicly-funded prgrams (i.e. LHIN r MOHLTC funded) with a primary rehabilitative care fcus prvided by r under the supervisin f regulated health prfessinals. Characteristics Medical / Healthcare Prfessinals Reprting Tls Functinal Trajectry Prgressin Maintenance Level f Care - Gal Target Ppulatin / Functinal Characteristics Transitin Indicatr Medical Care Nursing/Therapy Care Wellness/Health Prmtin Pst-Rehabilitatin Cmmunity Reintegratin* Wellness/health prmtin prgrams prvided by nn-regulated health prfessinals * after illness/injury t halt/slw disease prcess, help individuals manage health prblems and t supprt cmmunity reintegratin These prgrams shuld be cnsidered by prviders within the defined levels f rehabilitative care when discharge planning and transitining clients t self-management activities. Part B: Determine lcatin f cmmunitybased rehabilitative care Can the patient s/ client s functinal gal(s) be met in an utpatient/ cmmunity setting that is utside f the hme? *Refer t Definitins Framewrk fr Rehabilitative Care Is the verall functinal trajectry f rehabilitative care prgressin (i.e. t restre r maximize functinal abilities)? * Is the verall functinal trajectry f rehabilitative care maintenance (i.e. t prevent functinal decline/injury r maintain functinal perfrmance)? * Regardless f functinal trajectry, (i.e. prgressin r maintenance), if a client lives: At hme Refer fr In hme rehabilitative care services** In a LTCH Cntact the LTCH t discuss referral t rehabilitative care services. Cnsider ther care plans Based n patient/client cmplexity, the service delivery mdel (e.g. individual vs. grup) and setting (e.g. hspital-based r cmmunity clinic) that can best address gals f treatment, refer t: A single discipline r Interdisciplinary team r A specialized rehabilitative care service Based n patient/client cmplexity, the service delivery mdel (e.g. individual vs. grup) and setting (e.g. hspital-based r cmmunity clinic) that can best address gals f treatment, refer t: Cmmunity clinics / specialized rehabilitative care services (e.g. seating clinic, prsthetic clinic etc.) / ther resurces **In-Hme Rehabilitative Care Eligibility Typically a valid OHIP card is required and services are prvided by Cmmunity Care Access Centres. Fr eligibility, see Hme Care and Cmmunity Services Act, 1994, Ontari Regulatin 386/99, Sectin There may be ther lcal publicly funded prgrams with their wn requirements that are available *Nte: While wellness fcused health prmtin/preventin prgrams that are nt prvided by r supervised under regulated health prfessinals are beynd the scpe f the Definitins Framewrk fr Cmmunity Levels f Rehabilitative Care, it is acknwledged that such prgrams play an imprtant rle in the system by prmting verall health and supprting patients reintegratin int the cmmunity. Examples f these prgrams include: Grup exercise; wellness prmtin classes; swimming; walk-fit; yga; Tai-Chi; Pilates; peer supprt and friendly visiting prgrams. Cmmunity-Based Rehabilitative Levels f Care / Final / March 2015 Page 3

4 Patient Characteristics DEFINITIONS FRAMEWORK FOR COMMUNITY LEVELS OF REHABILITATIVE CARE (DRAFT 10) These definitins pertain t publicly-funded prgrams (i.e. LHIN r MOHLTC funded) with a primary rehabilitative care fcus prvided by r under the supervisin f regulated health prfessinals. Part A: Determine which level f cmmunity-based rehabilitative care wuld meet the needs f the patient/client Functinal Trajectry PROGRESSION 4 MAINTENANCE Rehabilitatin is fcused n enabling individuals with impairments and disabilities t reach and maintain their ptimal physical, sensry, intellectual, psychlgical and scial functinal levels and thereby prmte health and well-being, re-integratin t cmmunity living and imprve quality f life Level f Care - Gal Target Ppulatin / Functinal Characteristics Determinatin f where the client receives cmmunity-based rehabilitative care is based n which envirnment wuld be best suited t achieve the client s rehabilitative care gals including cnsideratin f resurce/equipment needs, individual vs. grup treatment mdalities, and the capacity f clients t travel utside f the hme. T prvide assessment and time limited treatment thrugh a single service r crdinated, inter-prfessinal apprach t: T prevent functinal decline/injury r maintain functinal perfrmance (e.g. strength, mbility, balance, falls preventin etc.) thrugh: Restre r maximize functinal abilities (including Individual assessment/treatment t address functinal impairments, including chrnic cgnitive capacities in all aspects f living) Prmte adaptatin f/t the hme envirnment t supprt re-integratin t cmmunity and verall quality f life Supprt timely transitin frm r prevent admissin t acute care r a bedded level f rehabilitative care Prvide the pprtunity t learn and practice in a familiar, stimulating and supprtive envirnment Individuals wh fllwing acute episdes r the wrsening f symptms due t a debilitating event r prgressive cnditin including chrnic disease, pain, injury r surgical prcedure: 9 Have functinal impairments resulting in decreased functin (e.g. reduced functining in ADLs, mbility, cmmunicatin, cgnitin, swallwing r mbility etc.) Require rehabilitatin t achieve functinal gals, increase self-management skills and maximize cmmunity reintegratin D nt require a bedded level f care disease self-management Peridic assessment and versight f care plan by regulated health prfessinal/team t determine the need fr engagement f additinal rehab prfessinals depending n client need and availability f family supprt r infrmal care netwrks Individuals with reduced physical/cgnitive/speech-language functining (e.g. neurmuscular, musculskeletal and cardi-respiratry etc.) wh require rehabilitative care t prevent a decline in functinal status and/r t prmte their capacity t remain at hme. Individuals living in the cmmunity (hme, retirement hmes, LTCHs) wh have functinal gals that can be met by participating in grup interventin, which culd include falls preventin classes. 10 Nte: Sme individuals, fr example thse wh are aging with a chrnic disability where a decline might be anticipated due t the nature f their health cnditin, may need t mve between the maintenance and prgressin levels f rehabilitative care in the event that a new functinal gal and treatment plan is identified (e.g. a client with Multiple Sclersis develping the need fr an Ankle Ft Orthsis r an aging client with paraplegia wh develps shulder stearthritis frm years f transfers). Cmmunity-Based Rehabilitative Levels f Care / Final / March 2015 Page 4

5 Medical / Healthcare Prfessinals DEFINITIONS FRAMEWORK FOR COMMUNITY LEVELS OF REHABILITATIVE CARE (DRAFT 10) These definitins pertain t publicly-funded prgrams (i.e. LHIN r MOHLTC funded) with a primary rehabilitative care fcus prvided by r under the supervisin f regulated health prfessinals. Part A: Determine which level f cmmunity-based rehabilitative care wuld meet the needs f the patient/client Functinal Trajectry PROGRESSION 4 MAINTENANCE Determined by the fllwing cnsideratins: When individuals have achieved their identified therapeutic bjectives / functinal gals as per the client s treatment plan r Determined by the fllwing cnsideratins: When individuals have achieved their identified therapeutic bjectives / functinal gals as per the client s treatment plan t prevent decline in functin r Reasnably equivalent gains can be achieved independently r with the assistance f a caregiver at Reasnably equivalent gains can be achieved independently hme r thrugh self-management r wellness/health prmtins classes (e.g. exercise classes) 12 Transitin r with the assistance f a caregiver at hme r thrugh selfcare r wellness/health prmtins classes (e.g. exercise Individuals have the pprtunity t transitin back int the Maintenance level if intermittent r ther apprpriate resurces in the cmmunity Indicatr classes) 11 r ther apprpriate resurces in the cmmunity r N further gains are likely t be achieved (i.e. a plateau has been reached) assessment and/r interventin are needed. Individuals may transitin t the Prgressin level f cmmunity-based rehabilitative care r t a bedded level f rehabilitative care t address the nset f a new cnditin r change in treatment plan Applicable t bth Medical and Healthcare Prfessinals Medical Care Healthcare Prfessinals Nte: At each transitin pint, mechanisms fr the crdinatin and cmmunicatin f the pst-discharge rehabilitative care plan with the receiving prvider(s) and patient and families/caregivers shuld be in place t supprt a successful transitin. 13 Rehabilitative care prvided by medical, nursing and allied health prviders: Is client-centred 14 and based n the client s assessed care needs and gals Includes a written plan f care fr each persn receiving the service Is crdinated and uses a cllabrative mdel f care where there are mechanisms in place t supprt effective case crdinatin/management and cmmunicatin amng all members f the rehabilitative care team and the primary care practitiner Invlves the client, family and/r infrmal caregivers in care planning, with the client s cnsent Medical care/management may be prvided by a primary care practitiner (e.g. Family Physician, Nurse Practitiner) as well as by thse fcused n rehabilitative care (e.g. physiatrists, geriatricians, paediatricians and/r ther specialists) Therapy services: Are prvided by r under the supervisin f a minimum f ne regulated health prfessinal r by an integrated, inter-prfessinal team f regulated health prfessinals (if mre than ne discipline is required) with expertise in the cnditin(s) fr which the client is being treated as well as sme understanding f assciated pre-mrbid cnditins. Sme prgrams may use therapy assistants under the supervisin f a regulated health prfessinal (e.g. PT r OT assistants) as part f the care team t increase the impact, intensity, adherence and supervisin f therapy. 15 Regulated health prfessinals may include but are nt limited t: Physitherapists, Occupatinal Therapists, Speech-Language Pathlgists, Scial Wrkers, Registered Nurses, Dietitians, Psychlgists, Chirpdists, and Kinesilgists May include interventins t imprve: ADL; cmmunicatin; cgnitin; swallwing; balance; lwer /upper extremity strength; mbility; ability t transfer/mve in bed; functinal transfers; seating and psitining; behaviurs; safety; adaptive equipment; cping including emtinal functining and adjustment t disability; independence and return t vcatinal activities May be primarily cnsultative r assessment-based fr assistive devices needs (e.g. seating clinics & Assistive Devices Prgrams; Augmentative Cmmunicatin Cmmunity-Based Rehabilitative Levels f Care / Final / March 2015 Page 5

6 DEFINITIONS FRAMEWORK FOR COMMUNITY LEVELS OF REHABILITATIVE CARE (DRAFT 10) These definitins pertain t publicly-funded prgrams (i.e. LHIN r MOHLTC funded) with a primary rehabilitative care fcus prvided by r under the supervisin f regulated health prfessinals. Part A: Determine which level f cmmunity-based rehabilitative care wuld meet the needs f the patient/client Functinal Trajectry PROGRESSION 4 MAINTENANCE Clinics) r t address ther impairments r disability (e.g. Spasticity Clinic; Vcatinal Rehab; Geriatric Assessment; Fllw-up appintments fllwing discharge) May be prvided in individual r grup frmat May include rehab grups that are led by a regulated rehab prfessinal r team f regulated health prfessinals t enhance an individual s ability t cpe with impairments, activity limitatins and participatin restrictins. 16 Healthcare Prfessinals Therapy Intensity Reprting Tls In the Prgressin level, therapy services: Are prvided t imprve, develp r restre functin lst r impaired as a result f de-cnditining, a health cnditin, pain, injury r surgical prcedure May include intensive rehabilitatin t supprt early discharge frm hspital r t prevent admissin t hspital In the Maintenance level, therapy services: Are prvided t maintain and/r t prevent a decline in functinal/clinical status as a result f de-cnditining, a health cnditin, pain r aging May invlve intermittent re-assessment/treatment and/r peridic versight by regulated health prfessinal/team t determine need fr engagement f additinal rehab prfessinals depending n client need and availability f family supprt r infrmal care netwrks May include falls preventin grup classes r ther wellness/health prmtin classes prvided by a physitherapist r ther regulated health prfessinal. In rder t align with best practices, fall preventin prgrams shuld be cmprehensive, 17 multifactrial 18,19,20 and may include but are nt limited t the fllwing cmpnents: Individualized risk assessment: 21 A brief risk assessment can be used t identify thse wh require a mre cmprehensive evaluatin based n risk factrs 22 and geriatric syndrmes. Such assessments may include a review f envirnmental hazards, including the hme; 23,24 visin screening 25 ; medicatin management 26 ; cntinence; nutritinal assessment 27 and ther risk factrs. Exercise: Exercise prgrams have been shwn t reduce the risk f fall recurrence These prgrams include strength training; 30,31 balance training 32,33 ; gait training 34 ; and advice n the apprpriate use f assistive devices. 35 Educatin: Educatin with clients, caregivers and prviders is recmmended as part f a cmprehensive apprach. It is imprtant t recgnize, hwever, that educatin alne des nt reduce the risk f falls 36,37,38. Tpics cvered thrugh educatinal effrts may include: imprving envirnmental safety, hw t safely change psitins, managing weather cnditins, and reducing fear f falling, amng thers. The number and frequency f services are based n the treating therapist s assessment, evidence-based best practices and the client s individual needs. Recmmendatins regarding a cmmn data set are currently underway by the RCA Outpatient/Ambulatry Task Grup Cmmunity-Based Rehabilitative Levels f Care / Final / March 2015 Page 6

7 DEFINITIONS FRAMEWORK FOR COMMUNITY LEVELS OF REHABILITATIVE CARE These definitins pertain t publicly-funded prgrams (i.e. LHIN r MOHLTC funded) with a primary rehabilitative care fcus prvided by r under the supervisin f regulated health prfessinals. Part B: After determining which level f cmmunity-based rehabilitative care is needed, refer t the decisin tree belw t determine lcatin f cmmunitybased rehabilitative care Referral Decisin-Making Tl fr Determining Lcatin f Cmmunity-Based Rehabilitative Care Can the patient s/ client s functinal gal(s) be met in an utpatient/ cmmunity setting that is utside f the hme? *Refer t Definitins Framewrk fr Rehabilitative Care Is the verall functinal trajectry f rehabilitative care prgressin (i.e. t restre r maximize functinal abilities)? * Is the verall functinal trajectry f rehabilitative care maintenance (i.e. t prevent functinal decline/injury r maintain functinal perfrmance)? * Regardless f functinal trajectry, (i.e. prgressin r maintenance), if a client lives: At hme Refer fr In hme rehabilitative care services** In a LTCH Cntact the LTCH t discuss referral t rehabilitative care services. Cnsider ther care plans Based n patient/client cmplexity, the service delivery mdel (e.g. individual vs. grup) and setting (e.g. hspital-based r cmmunity clinic) that can best address gals f treatment, refer t: A single discipline r Interdisciplinary team r A specialized rehabilitative care service Based n patient/client cmplexity, the service delivery mdel (e.g. individual vs. grup) and setting (e.g. hspital-based r cmmunity clinic) that can best address gals f treatment, refer t: Cmmunity clinics / specialized rehabilitative care services (e.g. seating clinic, prsthetic clinic etc.) / ther resurces **In-Hme Rehabilitative Care Eligibility Typically a valid OHIP card is required and services are prvided by Cmmunity Care Access Centres. Fr eligibility, see Hme Care and Cmmunity Services Act, 1994, Ontari Regulatin 386/99, Sectin There may be ther lcal publicly funded prgrams with their wn requirements that are available Cmmunity-Based Rehabilitative Levels f Care / Final / March 2015 Page 7

8 Endntes 1 See Definitins Task Grup Backgrunder Dcument, Octber Rehabilitative Care Cnceptual Framewrk. Develped by Definitins Wrking Grup fr the Rehabilitatin and Cmplex Cntinuing Care Expert Panel. Nv The cncept f functinality is derived frm the WHO/Wrld Bank Wrld Reprt n Disability, 2011 which describes functining as: An umbrella term in the ICF fr bdy functins, bdy structures, activities, and participatin. It dentes the psitive aspects f the interactin between an individual (with a health cnditin) and that individual s cntextual factrs (envirnmental and persnal factrs). 4 Cmmunity-based educatin prgrams such as grup exercise, activatin, r falls preventin classes r services prvided slely t maintain an existing level f functin are nt included within this level f care. 5 T prvide assessment and treatment(s) t imprve, develp r restre physical functin and/r t prmte mbility. Ontari Assciatin f Nn-Prfit Hme and Services fr Senirs. Physitherapy Clinical Table. A Guide t Physitherapy, Occupatinal Therapy and Exercise Service Prvisin in Lng-Term Care Ontari Ministry f Health and Lng-Term Care, Hme Care and Cmmunity Services Act, 1994, ONTARIO REGULATION 386/99, PROVISION OF COMMUNITY SERVICES 7 Ontari Ministry f Health and Lng-Term Care, Lng-Term Care Hmes Act, Ontari Ministry f Health and Lng-Term Care, Lng-Term Care Hmes Act, 2007, Ontari Regulatin 79/10 9 Ontari Ministry f Health and Lng-Term Care, Physitherapy Prvider Qs & As Publicly Funded Clinic Based Physitherapy Services. Octber Waterl Wellingtn LHIN. Questins & Answers. WW LHIN Exercise and Falls Preventin Classes Expressin f Interest Ontari Assciatin f Nn-Prfit Hme and Services fr Senirs. Physitherapy Clinical Table. A Guide t Physitherapy, Occupatinal Therapy and Exercise Service Prvisin in Lng-Term Care Ontari Assciatin f Nn-Prfit Hme and Services fr Senirs. Physitherapy Clinical Table. A Guide t Physitherapy, Occupatinal Therapy and Exercise Service Prvisin in Lng-Term Care Health Quality Ontari. Adpting a Cmmn Apprach t Transitinal Care Planning: Helping Health Links Imprve Transitins and Crdinatin f Care. Retrieved frm 14 Patient-centred care has been described as care that is respectful f and respnsive t individual patient preferences, needs and values with clinical decisins guided by patient values. See Institute f Medicine. Crssing the Quality Chasm: A New Health System fr the 21st Century: Cmmittee n Quality f Health Care in America. Washingtn, D.C: Natinal Academy Press; 2001 cited in Webster, F; Perrucci, A V; Jenkinsn, R; Jaglal, S; Schemitsch, E; Waddell, JP; Bremner, S; Mbili MH; Venkataramanan, V; Davis, A M. Where is the patient in mdels f patient-centred care: a grunded thery study f ttal jint replacement patients. BMC Health Serv Res. 2013; 13: 531.; Published nline Dec 23, In LTCHs, ccupatinal therapy and speech-language therapy are prvided by regulated health prfessinals and/r by supprt persnnel wh are members f the staff f the Hme wh wrk under the directin f a member f the apprpriate regulated health prfessin and the designated lead f the restrative care prgram; and scial wrk/scial services wrk Ontari Ministry f Health and Lng-Term Care, A Guide t the Lng-Term Care Hmes Act, 2007 and Regulatin 79/10, Sectins 59, 61 and Wrld Health Organizatin. Twards a Cmmn Language fr Functining, Disability and Health: ICF The Internatinal Classificatin f Functining, Disability and Health Internatinal Classificatin f Functining, Disability and Health (ICF) Mreland, J., Richardsn, J., Chan, D.H., O Neill, J., Bellissim, A., Grum, R.M. and Shanks, L. (2003). Evidence-based guidelines fr the secndary preventin f falls in lder adults. Gerntlgy, 49, Wrld Health Organizatin. (2007). WHO Glbal Reprt n Falls Preventin in Older Age. Geneva, Switzerland: WHO Press. 19 Mreland, J., Richardsn, J., Chan, D.H., O Neill, J., Bellissim, A., Grum, R.M. and Shanks, L. (2003). Evidence-based guidelines fr the secndary preventin f falls in lder adults. Gerntlgy, 49, Wrld Health Organizatin. (2007). WHO Glbal Reprt n Falls Preventin in Older Age. Geneva, Switzerland: WHO Press. 21 Mreland, J., Richardsn, J., Chan, D.H., O Neill, J., Bellissim, A., Grum, R.M. and Shanks, L. (2003). Evidence-based guidelines fr the secndary preventin f falls in lder adults. Gerntlgy, 49, Public Health Agency f Canada. (2005). Reprt n Senirs Falls in Canada. Retrieved March 17, 2009 frm 23 Mreland, J., Richardsn, J., Chan, D.H., O Neill, J., Bellissim, A., Grum, R.M. and Shanks, L. (2003). Evidence-based guidelines fr the secndary preventin f falls in lder adults. Gerntlgy, 49, Mreland, J., Richardsn, J., Chan, D.H., O Neill, J., Bellissim, A., Grum, R.M. and Shanks, L. (2003). Evidence-based guidelines fr the secndary preventin f falls in lder adults. Gerntlgy, 49, Public Health Agency f Canada. (2005). Reprt n Senirs Falls in Canada. Retrieved March 17, 2009 frm 26 Mreland, J., Richardsn, J., Chan, D.H., O Neill, J., Bellissim, A., Grum, R.M. and Shanks, L. (2003). Evidence-based guidelines fr the secndary preventin f falls in lder adults. Gerntlgy, 49, Wrld Health Organizatin. (2007). WHO Glbal Reprt n Falls Preventin in Older Age. Geneva, Switzerland: WHO Press. 28 Mreland, J., Richardsn, J., Chan, D.H., O Neill, J., Bellissim, A., Grum, R.M. and Shanks, L. (2003). Evidence-based guidelines fr the secndary preventin f falls in lder adults. Gerntlgy, 49, Cmmunity-Based Rehabilitative Levels f Care / Final / March 2015 Page 8

9 29 Recent research indicates that grup-based exercise is effective fr falls preventin, quality-f-life enhancement, and balance imprvements in the lder adults cmparable with traditinal hme exercise prgrams. See Martin JT, Wlf A,Mre JL, Rlenz E, DiNinn A, Renneker, JC. (2013). The effectiveness f physical therapist-administered grup-based exercise n fall preventin: a systematic review f randmized cntrlled trials. J Geriatric Physical Therapy. Oct-Dec; 36(4): Vgler, C.M., Sherringtn, C., Ogle, S.J., and Lrd, S.R. (2009). Reducing the risk f falling in lder peple discharged frm hspital: A randmized cntrlled trial cmparing seated exercises, weight-bearing exercises, and scial visits. Archives f Physical Medicine and Rehabilitatin, 90, American Geriatrics Sciety (AGS) Panel n Falls in Older Persns. (2001). Guideline fr the Preventin f Falls in Older Persns. Jurnal f the American Geriatrics Sciety, 49, Mreland, J., Richardsn, J., Chan, D.H., O Neill, J., Bellissim, A., Grum, R.M. and Shanks, L. (2003). Evidence-based guidelines fr the secndary preventin f falls in lder adults. Gerntlgy, 49, American Geriatrics Sciety (AGS) Panel n Falls in Older Persns. (2001). Guideline fr the Preventin f Falls in Older Persns. Jurnal f the American Geriatrics Sciety, 49, American Geriatrics Sciety (AGS) Panel n Falls in Older Persns. (2001). Guideline fr the Preventin f Falls in Older Persns. Jurnal f the American Geriatrics Sciety, 49, American Geriatrics Sciety (AGS) Panel n Falls in Older Persns. (2001). Guideline fr the Preventin f Falls in Older Persns. Jurnal f the American Geriatrics Sciety, 49, Wrld Health Organizatin. (2007). WHO Glbal Reprt n Falls Preventin in Older Age. Geneva, Switzerland: WHO Press. 37 Public Health Agency f Canada. (2005). Reprt n Senirs Falls in Canada. Retrieved March 17, 2009 frm 38 American Geriatrics Sciety (AGS) Panel n Falls in Older Persns. (2001). Guideline fr the Preventin f Falls in Older Persns. Jurnal f the American Geriatrics Sciety, 49, Cmmunity-Based Rehabilitative Levels f Care / Final / March 2015 Page 9