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Assess & Restore Virtual ForumNovember 1, 2018

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Rehabilitative Care Alliance

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2018 Assess & Restore Virtual ForumAcross the Continuum of Care


Agenda

4

1:00-1:10 WelcomeA&R Backgrounder

Charissa LevyExecutive Director, RCA

1:10-1:40 VON SMART Enhanced In-Home Program Mississauga Halton

1:40-2:10 The Home Independence Program (HIP) Central West

2:10-2:40 Central East Virtual Ward and Community Enhanced Recovery Program

Central East

2:40-3:10 Enhanced Service Delivery: Geriatric Care Coordinator/Lead for Senior’s Clinical Pathway Development

North West

3:10-3:40 Enhancing Assess & Restore Capacity within the Central LHIN

Central

3:40-4:00 Shared Provincial IndicatorsClosing

Gabrielle SadlerProject Manager, RCA

*Presentations are 20 minutes with 10 minutes Q&A following.

Assess & Restore Background Program

o Target frail seniors who have experienced a recent functional loss that puts them at high risk for long-stay LTC home placement.

o Aim to enhance timely and appropriate access to programs, increase capacity across all elements of an A&R approach to care and improve quality of care.

Ministry Investmento Base Funding


Assess & Restore Background Project Requirements

o Eligible projects were required to:• Fit within one of the five elements of an A&R approach to care, which

include: screening, assessment, navigation and placement, intervention and transitions home; and

• Demonstrate improved A&R outcomes across the province.

o A small number of shared inter-LHIN projects with provincial scalability have been encouraged, and LHINs are encouraged to release portions of their funding they cannot use to other LHINs


2017/18 A&R FocusMore than 33,000 older adults received care across

28 A&R initiativesObjectives Across A&R Initiatives:1) Enhance and improve access to restorative care services for older adults.2) Move care for older adults from facility-based to community-based, wherever possible, by implementing proactive models of risk screening and navigation.3) Improve outcomes for older adults by implementing best practice care, including comprehensive geriatric assessment and geriatric interprofessionalrehabilitative care. 4) An additional focus noted in 2017/18 was the development of a regional strategy to address the operationalization and sustainability of the initiatives.


2017-18 A&R Initiatives: Key Messages A cross-sectoral integrated approach to restorative care

improves outcomes for community-dwelling older adults

Proactive access to comprehensive assessment and restorative interventions improves outcomes and reduces avoidable admissions

Geriatric education and senior friendly care are essential components of successful A&R implementation

A planned regional strategy with an aligned vision is required to support a population health approach for frail older adults


RCA Annual Forum 2018Assess & Restore

Knowledge ExchangeMH LHIN Presentation

November 1, 2018Heather MacArthur, Victoria Order of Nursing

Amy Khan, Mississauga-Halton LHIN

SMART Enhanced Program

Evidence based gentle exercise program designed to restore frail, elderly, high risk seniors who have had a recent decline in

functional abilities.

Objectives:o Restore & improve mobility through exerciseo Improve/maintain functional independenceo Improve/maintain mental healtho Reduce hospital visits


SMART Program The Program is comprised of 2-in home visits per week for 6 weeks.

1. Referral Form2. Phone Screening3. Physician Clearance 4. Initial Assessment (Kinesiologist)

o Physiotherapist if needed5. Exercise Sessions (Exercise Leaders)6. Post Assessment (Kinesiologist)


Improving Health Care Delivery for Older Adults

Developed an upstream approach to promote healthy aging of olderadults, who otherwise might not have the opportunity to participatein traditional exercise due to access barriers.

Improved health care delivery:o One-on-one exercise sessionso Consistency of care

o Exercise Leadero Time of week/day



2017-2018 Results


Measurements Average Outcome Improvements

Comments

AUA 0.021 Minimal impact on AUA scores

Frailty Score -0.303 69.7% of clients had no change in their frailty score. Of the 30.3% of clients that had a change in their score, 88.9% saw an improvement by 1 point and 9.1% saw a decline

QoL 3.65 82% of clients had an improved QoL score

Berg Balance Scale 7.279 94.6% of clients had an improved BERG outcome

Timed Up & Go -5.353 70% of clients had an improved TUG score

Developing Integrative Models of Care

Engagement with cross-sectoral health care services including:o Care Coordinators

oMH LHIN, Central Registry, o Physicians

o Family Doctor, Geriatricians o Hospitals

o Trillium Health Partners, Credit Valley Hospitalo Health Service Providers

Challenges:o Primary Care Involvemento Meeting eligibility of Program

o Ageo Service Area


Key LearningsIssues for rehabilitative care for older adults:o Hospital admissions o Illness o Aches & Pains

Identified Next Steps After Completing the Program:o Conduct Exercises Independentlyo Train PSW or Caregivero Transition into group exercises classes


Opportunities to spread an A&R approach to care


o Opportunities for Home Exercise programs to partner with community physiotherapy clinics

o Improving Community Home Exercise programs to include pre and post standardized assessments to monitor progress

Questions?



Knowledge ExchangeCW LHIN Presentation

November 1, 2018Aruna Mitra

Director Home and Community Care

Home Independence Program 2017/18

What we set out to do…o To build on positive outcomes realized by Legacy Central

West CCAC Home Independence Programs (HIP) offered in 2015/16 and 2016/17 by:

• Streamlining program processes and resources• Establish a sustainable approach to A & R in Central West LHIN • Ensure program made available to patients who would most

benefit • Include more robust outcome measures


Learnings from past HIP experience


Opportunity to improve centralized screening and oversight resulted in inappropriate patients admitted to program

Availability of PSW as part of service package became an access issue for patients who had no other available option for PSW services which also impacted on program outcomes

Education needs for providers to reinforce and support a restorative approach in home care delivery

Home Independence Program

An 8-week home-based restorative care program designed using a best practice approach to improve seniors’ independence and prevent functional decline.

Patient program is led by an Occupational Therapist (OT) with activities assigned to PSW

Physiotherapy services are also available and the treatment was completed by personal support workers under the supervision of the physiotherapists.

Patients’ motivation is a significant element of the program and the OT’s worked collaboratively with patients to establish patient centered goals.


OT oversight

PSW

PATIENT GOAL

PT

HIP: Program Improvements 1. Refined patient criteria & intake process to include OT screening and

Frailty Index2. Standardized protocols implemented for communication between

therapist and PSW 3. Increased client centered approach with therapists – COPM

implemented & other interventions depending on the goals identified by the patients.

4. Dedicated Rehabilitation Care Coordinator provided operational oversight; SPO liaison; facilitated patient teleconferences

5. Orientation/ Training Session for all Rehab providers, including hands on workshop conducted by an Rehab Care Coordinator and training provided by a community OT for PSWs re importance of restorative approaches

6. Refined process map to clarify processes and roles7. Tracking & reports to support centralized program monitoring by rehab

Coordinator




Support continuum of care through hospital discharge support for vulnerable seniors

Community access through Home & Community Care Coordinators & Primary Care

Integrative approach optimizing by restorative rehab approach utilizing cost effective model (OT/ PT PSW)

Program Utilization

HIP 2017/18

Total # patients 200

Average Age 77

Rockwood Frailty Score 5 & 6 (mild to moderate frailty)

Length of Stay in Program 8 weeks (56 days)

OT Average Utilization per patient 3 visits

PT Average Utilization per patient 3 visits

PSW Average Utilization per patient 12 visits

Budget $376,000


HIP Referral Sources


10%

14%

6%

56%

3%

11%

Primary CareCommunityHospital EDHospital InpatientHospital OutpatientOther LHIN

n= 200



42

22

INTAKE DISCHARGE

Timed Up and GO

3.1

6.1

2.9

6.1

INTAKE DISCHARGE

COPM Performance & Satisfaction

COPM-P COPM-S

Outcome Measures

Performance Score Change: 3Satisfaction Score Change: 3.2 TUG Score Improvement: 20



61%

12%

INTAKE DISCHARGE

Reduction in Falls

61%

10%

INTAKE DISCHARGE

Reduction in ER Visits

Reduced Falls & Prevented Hospitalization

49 % Reduction 51% Reduction



3%

22%

45%

29%

WORSE SAME SOMEWHAT BETTER MUCH BETTER

Self-Reported overall outcome on general wellbeing

74 % reported wellbeing as “somewhat better” & “much better”

Key Learnings The importance of consistency in scheduling of PSW’s Availability of PSW’s (shortage in Ontario and availability in all sub-

regions) impacted program Training of SPOs and PSW in Restorative care approach is key to

program success Oversight by Rehab Care Coordinator to monitor outcomes We are exploring role of incorporating OTA and PTA Sub-region alignment of the Service Provider Organization may

provide additional efficiencies Funding limitation reduced availability of program



Model can be incorporated across other LHINS to support transition for frail seniors from hospital to home for

Optimizing role of OT and PT through training of PSWs to practice skills (rather than “doing for”)

Rehab Coordinator Role Clinical tools and resources

o HIP Protocols o Process Map o Education Training Materials


Acknowledgements Archana Arun, Rehabilitation Care Coordinator

Jackie Minezes, Manager Home and Community Care

Kimberley Floyd, VP Home and Community Care

Home and Community Care Coordinators in community and hospital settings

CW LHIN Decision Support & Finance teams


Questions?



Knowledge Exchange CE LHIN Presentation

November 1, 2018Liora Krinsky

Clinical Practice Leader, Scarborough Health NetworkAngie Saini

Director of Care, Carefirst Seniors and Community Services Association

A Soft Landing: The Patient Journey from Hospital to Community Care

Scarborough Health Network (SHN) and Carefirst Seniors and Community Services Association’s Transitional Care Centre (TCC) established a partnership to provide patients and caregivers seamless transitions across the health care continuum from acute care (SHN) to a facility-based Assess and Restore intervention (TCC) then back into the community.



Program Objectives:o Extend beyond strengthening, reconditioning and returning to previous

level of functioningo Provides participants and caregivers with access to services to improve

or maintain their abilities to enable them to continue to live independently in the community including home care, exercise and falls prevention classes, and chronic disease management programs.

o Collaborates with primary care to manage clients and ensure appropriate follow-up post-discharge.

o This restorative program is an innovative model that provides wrap around care that continues once the participants have been discharged home from TCC



The partnership between SHN and Carefirst provides seniors who require reconditioning after their acute medical illness access to physiotherapy, nursing, personal support, social work and community support services.

This A& R Intervention has two key components: 1) Virtual Ward Program (VW): Assist the patient in meeting VW’s five milestones:

o follow-up with primary care;o medication reconciliation;o tests/specialist appointments;o health education; and o linkage to appropriate community services

2) Enhanced Recovery Program: Individual treatment for those experiencing significant cognitive/physical/functional impairment; health teaching i.e., falls prevention, energy conservation; and functional training i.e. gait, transfer and home safety equipment training


A Soft Landing: The Patient Journey fromHospital to Community Care

o SHN, Carefirst, and the Central East LHIN ensures individuals are supported in a timely, coordinated and seamless manner as they move from SRH to Carefirst TCC and then back into the community with the necessary supports in place to enable them to continue to live in their homes for as long as possible.



o Participant/caregiver goals are identified prior to discharge by the inter-professional hospital team. Once the participant transitions to TCC, the care team then leverages all available resources in order to assist participants in achieving their goals and reintegrating them back into the community, including:

• Meals on Wheels, • LHIN’s Telehomecare program for participants with CHF or COPD• Carefirst’s COPD Community Rehabilitation program, • Geriatric Assessment and Intervention Network or GAIN team, • Diabetes Education Program• Community exercise and falls prevention classes• Caregiver support groups, etc.



The collaboration between SHN and Carefirst was developed to ensure that seniors who are at high risk for not being able to return home, receive the reconditioning to enable them to continue to live in the community independently. This restorative program is an innovative model that allows:• A safe, comfortable environment for seniors to gain their strength,

mobility, and confidence • Access to an interdisciplinary team that can manage their psychosocial

and physiological needs after an acute hospitalization which can be overwhelming for both seniors and their caregivers

• For a more comprehensive look at the participants’ and caregivers’ needs and subsequent access to all community resources including LHIN services to prevent them from returning to hospital

• Additional benefit of much needed respite for caregivers



The collaboration between SHN and Carefirst transcends the boundaries between acute care and community care however it is not without its challenges including the following:• Access to information: difficult to gather medical and social history

particularly for those admitted from ER. Also for this reason, difficult to assess whether they are appropriate for the program. To resolve this, Carefirst is provided with access to appropriate hospital IT platforms and is in the midst of trying to secure access to ConnectingOntario

• Difficult to coordinate admissions to TCC on evenings and weekends • Initially client may have shown potential for rehabilitation but plateaued,

making discharges back into the community more difficult• Participants who have high social needs, making discharge planning more

complex. do not have a firm discharge destination or who’s discharge destination changes once on TCC



The partnership does have components that work well: • Face to face meetings with potential participants and caregivers provides

warm transfer from hospital to TCC• Social workers from both organizations collaborate with

participants/caregivers to ensure a smooth transition and provide clear expectations



Lessons Learned: • Target population was reevaluated as the program proved inappropriate

for high need participants • Referral form was modified to reduce duplication in the collection of

information from the client/caregiver. SHN provides basic information to provide general picture, Carefirst does thorough face to face assessment in hospital

• Lab work services was initially a barrier but has since become incorporated into pathway

• Participants are at a higher risk of readmissions, but readmission rate remained the same as those discharged from hospital. Mitigation: NP hired at Carefirst to provide more robust clinical oversight



Opportunities for spread: The collaboration and integration of acute care and community care is essential in ensuring that patients are discharged from hospitals in a safe, effective manner that optimizes their well-being, reduces caregiver burden, reduces length of stay and prevents readmissions.


Key LearningsCapacity planning: o SHN’s goal has been to maintain a constant occupancy of 3 beds.

Carefirst is able to provide additional beds if it has the capacity to do so. This has not yet been an issue. As we expand to other SHN sites, it is something to consider

System gapso There is limited access/funding for this type of transitional care

setting in the Central East LHIN. Funding for these beds comes from the operational budget of SHN.

o There are other ‘transitional care’ settings but most do not have access to as comprehensive a basket of restorative and community support services as that offered at Carefirst

Next steps:o Increase hospital funding for such programs as part of total joint or

chronic disease pathway as a means to improve patient/caregiver experience, reduce length of stay, reduce readmission rate, and improve population health



Key Success Factors:• Integration of the acute care sector with community-based inpatient

rehabilitation and community support services to provide restorative then supportive care to sustain seniors/caregivers once they return home

• Focus on prevention: Leverage chronic disease management programs to provide patients and

caregivers the resources/education/tools they require to better manage their health care conditions

Connect patients and caregivers with other community programs that optimize their physical/emotional/cognitive well-being like exercise and falls prevention classes, Adult Day Program, etc.

Ensure follow-up with primary care and provide clinical oversight in the interim

• Collaboration across sectors: primary care, acute care, community care including the LHIN share the same goals –enable patients/caregivers to thrive in the community while contributing to the sustainability of the health care system


Questions?



Knowledge ExchangeNW LHIN Presentation

November 1, 2018Susan Veltri RN., Geriatric Care Coordinator

Emergency Identified Fast Track Service


Identification of “At Risk Seniors”who access the Emergency Department and implementation of a Clinical Pathway aimed at

enhanced care for Frail Seniors through referral to the Geriatric Care Coordinator

Pathway includes:o Rapid access to geriatric consultation and enhanced community care

and other related service with the objective of preventing avoidable ED visits, preventing hospitalization and reducing length of stay

o Primary Care while not directly related to the care at the hospital have been included in the Clients’ as the person progresses through the pathway



“Frail Senior” patient aged 65+ and exhibiting anysymptoms indicating risk presents to TBRHSC ED

Patient presents with :Cognitive Impairment/Delirium/Dementia,Anxiety/Depression, Poly-pharmacy/Medication Issues, PsychosocialIssues/Caregiver Stress, Falls/Weakness/Mobility Issues, Behavioral

Difficulties, Functional Decline/Frailty, Medical Concerns/Multiple Comorbidities, Complex Medical Issues, Weight Loss/NutritionalConcerns, Infection, Pain, Discharge plan follow-up, Fractured

Hips/Pelvis, Safety Concerns, Frequent Emerge Visits and/or Multiple Hospital Admissions, Any Other Concerns



Medical Stability Not safe for homeTBRHSC ED to SJCG Inpatient Geriatric Rehab Bed

Medical Stability Safe to go homeGeriatric Care Coordinator Facilitation of appointment at SJCG Rapid Access Geri Clinic Completion of CAM, Frailty, PPS, Depression Screen and Electronic Geriatric

Intervention and any other assessments as required GCC completes Home Care RR RN referral to NW LHIN GCC will make other referrals as appropriate to community agencies

Home Care Rapid Response RN NW LHIN RR RN completes CAM, Frailty, PPS standardized home assessment

and medication reconciliation

All information gathered by the GCC and RR RN are forwarded to the Geriatric Clinic prior to the Clients appointment



Improved Health Care Deliveryo Since the Clinical Pathway Process begun patients have received the benefit

of rapid access to Geriatric Consultation and resultant in-patient rehab post the appointment or on-going follow-up with the geriatrician as well as medical care specifically designed for the aging population

o Since the Pathway was established mid September 2017 until mid September 2018 Fifty Six (56) patients were enrolled in the process there by either preventing admission to hospital or promoting discharge from an overflow bed in the ED

o Emergency Department Physicians were very pleased with the process and engaged with Rapid Geriatric Consultation as an alternative to hospital admission

o Many concerning issues were identified through the process and therefore community service implemented to meet the clients ongoing needs to assist this group of Seniors to remain at Home

o TBRHSC, SJCG and the NW LHIN Home Care Division worked as a Collaborative Team in the enhancement of care for the identified “At Risk Seniors”



Collaboration between TBRHSC, SJCG and NW LHINo One of the biggest challenges in working together on the

Pathway was communication and education to the multiple health care providers who were involved in the process

o Another process problem was that it was somewhat person dependant – either Geriatric Care Coordinator, Geriatrician or RR RN availability

o Most appointments were scheduled within a week time frameo Patients and families were very pleased with the processo Emergency department staff and doctors were very pleased

with the addition and assistance from the Pathway Team


Key Learningso Capacity and ability to identify then serve the growing number of

Seniors in our community is key. TBRHSC has a very busy ED and many of the patients who present are over 65 years

o Gaps identified : 24 X 7 coverage of Team members, availability of geriatricians to meet the demand, availability of community resources to meet the needs of our aging population

o Ability of the system to adapt to the varying numbers of referrals –example: some weeks there were multiple referrals and other weeks there were zero

o In the coming months TBRHSC and SJCG will enhance the Pathway work through the addition of an additional GCC for extended hours and weekends as well as in home support through a OT and/or PT home visit



o Clinical tools and resourceso The GCC and the RR RN both used and forwarded assessments to

the Geriatrician including the CAM, Depression Screen, Cognition Screening, Frailty and PPS as well as Medication Reconciliation and Comprehensive Clinical Assessments

o A consistent approach was key to the team members o Information and collaboration occurred between TBRHSC, SJCG, NW

LHIN and Family Care Providers in a consistent approach to patient care

o Primary Care Providers were included in the process especially surrounding medication changes/additions that occurred either at the hospital or the Geri Clinic


Questions?



Knowledge ExchangeCentral LHIN Presentation

November 1, 2018Susan Woollard

Interim Vice President Clinical Programs, Quality and Risk, Chief Nursing Executive North York General Hospital

Mary BurelloDirector, Home and Community Care

Assess and RestoreAssess and Restore model developed in partnership between Central LHIN and North York General Hospital

The purpose of the Assess & Restore (A&R) program is to identify frail seniors who have the potential to regain functional ability as a result of illness or decline in health. Through a system approach, the goal for the patient is to regain functional independence to a point that they can safely return home and stay in the community.


Project DescriptionFoundational elements:

Hospital The MOVE Project Hourly Rounding and Bedside Reporting Electronic Confusion Assessment Method (eCAM) Tool Malnutrition Screening Tool Assessment Urgency Algorithm (AUA) Tool Weekend Mobilization & Activation Team Enhanced client rehabilitative services in hospital and home Dedicated Care Coordinator role in hospital and community

Community Specialized Geriatric Services (SGS) Single provider agency supporting community in-home services Dedicated Care Coordinator


Improved Health CareDelivery for Older Adults

Benefits of Program

Early identification in ED using AUA Tool (assessment urgency algorithm) Standardized level of rehab services in the inpatient services at NYGH Enhanced rehab services at home through Central LHIN Home and

Community Care Consistent Care Coordinator from hospital to home Follow up post discharge with Outpatient Services at North York Seniors

Health Centre (Assess and Restore therapy – modified Day Hospital ) Measuring outcomes Primary Care Follow up

Putting our arms around the patient from beginning to end of program


Indicators & OutcomesAn increase in inpatient therapies compared to baseline: ✓✓ 40% more physiotherapy ✓✓ 52% more occupational therapy ✓✓ 127 interventions completed by registered dietitians on weekends

For patients who completed the Assess and Restore program, significant improvement was noted in: CHESS Scale ✓✓ Berg Balance Scale ✓✓ MAPLe Priority Levels 31% ALC rate for post-acute inpatient rehabilitative care (Medicine cases only) 7% Unplanned readmission to hospital within 30 days of discharge 1% Unplanned, less urgent emergency department visits within 30 days of

hospital discharge


Indicators & Outcomes (continued)SYSTEM-LEVEL INDICATORS: ✓✓ Timed Up and Go Test ✓✓ Tinetti Gait and Balance Assessment Tool ✓✓ Activities of Daily Living Self-Performance Hierarchy Scale (RAI-HC)

CONCLUSION: Improvement noted in rehab functional scales and outcome measures of

the RAI-HC, including Time Up and Go Test and Activities of Daily Living Hierarchy. Patients satisfaction was very high with the comprehensive care and outcomes.



Successes Partnership with Central

LHIN Home and Community Care

Self-assessment with current services

Knowledge translation and coaching across the LHIN (road show model)

Tool Kit


Challenges Large numbers of staff to be

trained in hospital and community

LHIN boundaries for providing Home and Community Care follow up

Transportation to follow-up activities

Determining appropriate patients for program

Key Learnings Engage stakeholders early Share outcomes with team members Key foundational elements are building blocks to growing

your own Assess and Restore program System integration is the right pathway for patients Benefits of focused co-ordination and good communication

for discharge planning Culture of Senior Friendly is rewarding and exciting




Questions?


2017-18 Assess & Restore Shared Provincial Indicators

66

Summary of Recommended A&R Provincial Indicators

Proposed Provincial A&R IndicatorIndicator

within MOH Report

Template

Primary Care

Initiatives

Home & Community

Care Initiatives

Emergency Department

Initiatives

BeddedCare

Initiatives

1. Volume of patients/caregivers served

2. % admissions to rehabilitative care beds that were directly admitted from community/ED

3. % of unplanned readmission to hospital within 30 days of discharge from hospital

4. % of unplanned, less-urgent ED visit within the first 30 days of discharge

5. ALC Rate for A&R Patients

6. Improved Function (ADLs) 7. Rate of Discharge Home vs Baseline or other

Comparator

8. Referral rate for community-dwelling frails seniors screened at-risk for loss of independence


Volume ofPatients/Caregivers Served: Community Base Programs

68

0 100 200 300 400 500 600 700 800

SW LHIN - Geriatric Ambulatory Access Team

SW LHIN - Evaluation of Implementing Proactive Screening with…

WW LHIN - Rapid Recovery Therapy Program (RRTP)

CW LHIN - Home Independence Program

MH LHIN - VON SMART Enhanced In-Home program

MH LHIN - Community Step-Up Clinic

MH LHIN - Assess and Restore Clinic – HHS

CEN LHIN - Enhancing A&R Capacity Central LHIN - In Home

CEN LHIN - Enhancing A&R Capacity Central LHIN - Out-patient

CE LHIN - Virtual Ward & Community Enhanced Recovery Program

CE LHIN - CATCH (Care After The Care in Hospital) Program

CH LHIN - Central Intake for Specialized Geriatric Services

NSM LHIN - Enhanced SMART and Transitions of Care

TC LHIN - West Park Assess & Restore

TC LHIN - Providence Health Care Assess & Restore Services

TC LHIN - Independence at Home (IAH) Program - UHN & SHS

2016-17 2017-18

Total of 10,265 patients served in A&R Community Based Programs

Volume ofPatients/Caregivers Served:

Hospital-Based Programs

69

0 500 1000 1500 2000 2500 3000 3500 4000 4500

ESC LHIN - Bluewater Health Mobilization of Vulnerable Elders…ESC LHIN - Chatham Kent Mobilization of Vulnerable Elders…

ESC LHIN - Erie Shores Mobilization of Vulnerable Elders (MOVE)…ESC LHIN - Windsor Regional Metropolitan Campus Mobilization…

ESC LHIN - Windsor Regional Oulette Campus Mobilization of…SW LHIN - London Health Sciences Enhanced Rehabilitative Care…

HNHB LHIN - Seniors Mobile Assess & Restore Teams (SMART)CEN LHIN - Enhancing A&R Capacity Central LHIN

CE LHIN - Northumberland Hills Assess and Restore InterventionCE LHIN - Ross Memorial Hospital Assess & Restore Mobile team…

CH LHIN - The Ottawa Hospital 7 day/week Therapy in ABI RehabCH LHIN - The Ottawa Hospital Pilot Direct Admissions to Sub-…

NW LHIN - Assess & Restore Expansion at Sioux Lookout Meno Ya…NW LHIN - Dryden Regional Weekend and Enhanced OT for A&R…

NW LHIN - Thunder Bay Regional Enhanced Service Delivery: …NW LHIN - St. Joseph's Care Group Geriatric Assessment and…

TC LHIN - Salvation Army Toronto Grace Health Centre Integrated…SE LHIN - Quinte Health Care

2016-17 2017-18

Total of 23,064 patients served in

A&R Hospital-Based Programs

Percentage of admissions to rehabilitative care beds that were

directly admitted from community/ED

70

0 10 20 30 40 50 60

CE LHIN - Northumberland Hills Assess and RestoreIntervention

NW LHIN - St. Joseph's Care Group Geriatric Assessmentand Rehabilitative Care

TC LHIN - Providence Health Care Assess & RestoreServices

2016-17 2017-18

The following sites reported number of direct admissions:

NE LHIN – Assess & Restore/Geriatric Rehabilitative Care – 33 admits

NW LHIN – Thunder Bay Regional Enhanced Service Delivery – 16 admits

TC LHIN – Providence Health Care Assess & Restore Services – 167 admits

Average FIM® Total Function Score Change

71

0 5 10 15 20 25

CE LHIN - Northumberland HillsAssess and Restore Intervention

CE LHIN - Ross Memorial HospitalAssess & Restore Mobile team

(ARM)

CH LHIN - The Ottawa Hospital 7day/week Therapy in ABI Rehab

NW LHIN - Assess & RestoreExpansion at Sioux Lookout Meno Ya

Win Health Centre

2016-17 2017-18

Additional validated tools used to report functional changes:• Timed Up and Go• Berg Balance Scale• 2 Minute Walk Test• Grip Strength• COPM• ASHA NOMS FCM• MOCA• Chedoke-McMaster

Stroke Assessment• Barthel ADL Index

Rate of Discharge Home

72

0 10 20 30 40 50 60 70 80 90 100

CEN LHIN - Enhancing A&R Capacity in Central LHIN

CE LHIN - Virtual Ward & Community Enhanced Recovery Program

CE LHIN - Northumberland Hills Assess and Restore Intervention

CE LHIN - Ross Memorial Hospital Assess & Restore Mobile team…

ESC LHIN - Bluewater Health Mobilization of Vulnerable Elders…

ESC LHIN - Chatham Kent Mobilization of Vulnerable Elders…

ESC LHIN - Erie Shores Mobilization of Vulnerable Elders (MOVE)…

ESC LHIN - Windsor Regional M Mobilization of Vulnerable Elders…

ESC LHIN - Windsor Regional O Mobilization of Vulnerable Elders…

HNHB LHIN - Seniors Mobile Assess & Restore Teams (SMART)

NW LHIN - Assess & Restore Expansion at Sioux Lookout Meno Ya…

NW LHIN - Dryden Regional Weekend and Enhanced OT for A&R…

TC LHIN - Assess and Restore Initiative - Providence, St. Joseph…

2016-17 2017-18

Questions?


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