Care Settings and Coordinated Transitions

Rehab Care

• An essential part of universal health coverage

• Provided across the continuum of care

• Seamless transitions of supports suc esful return to community settings

• Integrate rehab hlth systems

Rehab care and ON Hlth Teams

1. Ensure rehab care providers @ planning table

2. Get input from pts/clients who have received rehab care

3. Identify all services where rehab care should be integrated

Recovery happens in a system?

• Recovery happens across a system where patients live, seek care, and recover

• Beyond treating conditions to navigating systems of care

Care Settings Cross the Continuum - Institutional Settings

• Acute hospital

• rehab hospital/beds

• Complex continuing care

• LTC

• Mental health + addiction hospital/facility

• Palliative care

Care Settings Cross the Continuum - Community based Settings

• Family health

• Group professional practice

• Solo professional practice

• Home care

• School board + school-based rehab services

• Industry, manufacturing + commercial

• Assisted living/residential care facility

• Public health

• Supportive housing

• Other programs + services

Where rehab care is provided

1. Hospitals: acute, rehab, transitional care

2. Home care: gov funded

3. Long term care

4. Primary health care: community health centres, PT clinics [government funded, private]

5. Other: school board + school based rehab services

Virtual PT practise - Benefits

• Improves access

• Tele-rehab

• Alternate mode of service delivery

• Does not remove or alter existing responsibilities for the provider

• Removes commute, disinfection, decreases non-attendances/cancellation patients opt out

• Facilitates urgent visits

• Focus on active treatment, patient education, and self-management

• Exercise and patient education

• Removes commute for those who have pain standing

CPO Virtual Practice

• Expectations related to virtual practice

• Registered to practise in ON

• Physios assessing or treating patients in another jurisdiction must be registered to practise in that jurisdiction

Physio’s role in hospital

Short + long term stays after discharge

Support all ages and stages of life + recovery from illness or injury

Rehabilitative Care Alliance

Find hospitals in the area that meet their intensity of rehab to fit their needs

Also sort by private in home and clinic

ON Health @Home

• Home

• Community

• LTC

• Supportive Living

• Health line

• Family doctor

Requires a referral from ANYONE

Is Homecare funded by gov?

Yes, by the Ministry of Health

Administered by ON Health @Home

Determine eligibility, level of care, and duration

Care coordinator manages client’s case

Services included in Home Care (ON Health @ home)

Nursing

PSW

PT, OT, SLP

Social work/nutrition counselling

Med supplies + equipment

Palliative care

Community clinics for: IV, wound care, injections, post-surgical care

What is respite care?

Short stays in LTC

Must be eligible

Arranged w/ ON Health @ home

Governing body for LTC

Ministry of LTC funds, regulates, inspects, sets fees for LTC

GOV FUNDED

Costs regulated by gov accomodation rate

Annual inspection

How to get into LTC

ON Health @Home Care coordinator assess eligibility and help w/ application.

PTs Role in LTC

Focus on mobility, strength, balance, and flexibility.

Maintain + gain fxn

Reduce fall risks

Stay active to do what they love

What is Primary Care?

Foundation for good hlth care system

Focuses on hlth care services: health promotion, illness and injury prevention, diagnose + treat illness & injury

1st point of entry into health system

4 C’s of Primary Care

1. 1st contact access where most enter the system

2. Continuous: long-term relationship with the patient. build trust

3. Comprehensiveness diverse range of hlth promotion, prevention, protection, treatment, rehab, palliative services

4. Coordination: organized + integrated over time

*5. Patient centered

What is high quality primary care?

• Whole person

• Integrated

• Accessible and equitable hlth care

• Adress person’s hlth + wellness needs

  • Patient is active participant

PTs in Primary Hlth Care

• Hlth promotion _ disease prevention

• Maximize mobility across the lifespan

• Ensure continuity of care across care continuum

Gov funded PT @ community physio clinics

Publicly funded PT

Requires a signed contract/transfer payment Agreement (TPA) w/ Ministry of Health ON

Funding based on Episodes of Care model

Set $ amount of public funding by EOC

1 diagnosis for 1 episode of care.

• All eligibility criteria met by the person

Who’s eligible for Gov Funded Community PT services?

65+/>19

Any overnight hospital stay or day surgery (within 12 mos)

Gets OW/ODSP

Find location on MOH page

Ways to find a PT

College of Physiotherapists of ON (public registrar)

ON Ministry of Health

Rehab care alliance

Physio’s within schools

Hired by the school board

Act as consultants to improve school performance for PwD

Interdisciplinary manner + collaborate

Schools Tiered Approach to Support Inclusion

Support the whole school board

• Education, consultants, supports

1. Universal programming

2. Targeted group intervention

3. Intensive individual instruction/intervention

What is a critical transition of care?

Hospital to home

• Home is usual place of residence [retirement home, assisted living, LTC, hospice, shelters]

Skills required in care transition?

Integrated communication especially at:

• Communication plan to HCP taking over

• Performing med reconciliation + post-discharge med adherence

• Arranging transportation + equipment @ home

Coordination w/ patient, caregivers, hospital team, primary care, and home community care providers

• Follow-up care

Components of Effective Care Transitions

1. Hospital shares info w/ primary care doc, home care providers, and specialists quickly. Community providers share all relevant info w/ admitting team in a timely manner

2. Comprehensive assessment of current health care and social support needs

3. Patient, family, care partner involved in transition planning

4. Educate + train families + care partners to manage care needs. Refer to community-based resources, med, equipment

5. Written transition plan

6. Name a doc responsible for timely transition planning, coordination, communication. Effective transfer of transition plans + information related to ppls care.

7. Structured med review during admission, be4 go home, once @ home

8. Follow up medical care w/ primary doc or specialist booked fore be4 leave hospital

9. Assess for type, amount, appropriate timing of home care and community support services

PT Accountability in Care Transition

Patient + family @ centre of transition planning. Address needs, concerns, and goals

Ensure continuity of care

Best interest of patient »»

• Evaluate patient outcomes + goals

• Develop plan

• Prepare patient for discharge

• Effective info transfer

We help patients navigate systems of care

Fragmentation

• Little continuity between different sectors of the healthcare system

• Ignore multi-dimensional factors that influence health

• Vulnerable for hospital related harm and deconditioning

Who makes discharge order?

Attending health care provider in consultation w/ team

What is discharge planning

Critical link btwn treatment in hospital by patient + post-discharge care provided in community.

Effective discharge benefits

• Supports continuity of quality health care btwn health care settings + community

• Reduce hospital stays + unplanned readmission

• Improves coordination of services after discharge

Legal requirements for admission + discharge in hospital. Policies + procedures in place

EDD

Estimated/expected date of discharge

When does discharge planning start?

PRIOR to patient being ready for discharge

@ admission

IDEAL Discharge

Include family + patient as partners

Discuss: what life @ home will be like, review meds, highlight warnings + problems, explain test results, make follow-up appts

Educate in lay terms their condition, discharge process, and next steps

Assess how well docs/nurses explain diagnosis and next steps. Have them explain it back.

Listen + honor goals and preferences and concerns