expanding patient-centred in-home physiotherapy …hssontario.ca/who/conference/documents/june 9,...

Expanding Patient-Centred In-Home Physiotherapy Services

to Support a Range of Patient Needs and Goals

Central East CCAC

Mississauga Halton CCAC Central West CCAC

Physiotherapy Reform

The report, “Living Longer, Living Well” (Sinha 2012), promotes improved mobility for seniors to help them live safely and independently at home as long as possible. In response, the Ministry of Health and Long-Term Care launched an initiative to reform PT services including in-home PT services. • CCACs: $33 million in annualized funding to expand the

provision of in-home physiotherapy services to 60,000 seniors/other patients and clear the physiotherapy wait list

• Falls Prevention and Exercise Classes: $10 million to provide exercise and falls prevention classes

• Others: PT Clinics, Long Term Care Home and Primary Care Services

Transition from OHIP funded Physiotherapy Services

Initial Priorities during the Transition Period • Eliminating waiting lists for in-home physiotherapy. • Identifying and transitioning patients receiving OHIP-funded

physiotherapy (ended on August 21st, 2013). • Streaming to appropriate services

In-home physiotherapy Exercise classes Falls prevention Other services

Magnitude of the Transition CCACs and SPOs successfully collaborated to transition over 32,000 patients in over 1,000 sites across the province, bringing 23,300 on to care over a four month period.

OH

IP I

n-ho

me

Phys

ioth

erap

y

Goal-oriented Physiotherapy

Patients needing long-term support to maintain function

and prevent decline

Patients who really need PSS services

People who need referrals to other services (e.g., pain

management)

CSS Exercise Classes

People needing 1:1 help to access classes

CSS Falls Prevention

Assumptions prior to the transition

Additional needs

Physiotherapy Advisory Panel Recommendations

In June of 2013, an advisory panel was established to review the literature and recommend evidence-informed practices to support the development of new,

patient-centred models of care.

• Led by Cathy Hecimovich (CEO of Central West CCAC), membership included experts from geriatrics, the rehabilitation sector and the physiotherapy profession along with CCAC and OACCAC representatives.

• Recommended a number of evidence-informed innovations including: • support for an expansion of PT scope of practice in home care, • integration of physiotherapist support personnel, • focus on outcome-focused service delivery to serve the needs of different in-home

physiotherapy patient groupings, • self-management models.

To operationalize the recommendations and support the needs of this new population, a provincial working group came together to develop the

PT service delivery model of care.

In-Home Physiotherapy Service Delivery Model

In-Home Physiotherapy

Stream 3: Maintenance Goal: Maintain & Prevent

Decline in Function

Stream 2: Restorative Goal: Restore Optimal

Function

Stream 1: Rehabilitation Goal: Improve & Restore

Independent Function

Patient-Centred, Evidence-Informed Care

• Operationalization of the model of care for PT: • expands the capacity of in-home PT service delivery to address a range of

patient needs and goals (rehabilitation, restorative and maintenance). • reinforces outcome-focused care delivery. • brings province-wide consistency to the delivery of in-home physiotherapy

services while allowing for local variation. • enables the health care system to better support seniors to live as safely and

independently as possible.

• Ongoing work: • CCAC sites continue to engage locally with SPOs and retirement home

operators to operationalize the recommendations. • OACCAC and CCACs continue to engage with provincial associations: ORCA,

OCSA, OHCA, APACTS. • Implementation and testing continues: based on local needs and conditions,

each CCAC is choosing to implement recommendations according to those needs.

Site Perspectives

Physiotherapy Reform and Physiotherapy Transition in Central East CCAC

Laszlo Cifra Program Director, Integrated

Care, CE CCAC

Michelle Nurse Director, Contracts and

Relationships, CE CCAC

Implementing the New Physiotherapy Model: Successes, Challenges & Key Learnings in

Mississauga Halton CCAC

Carey Lucki Program Manager, Patient Care,

MH CCAC

Physiotherapy and Exercise and Falls Prevention Program in Central West CCAC

Kimberley Floyd Director of Client Services,

CW CCAC

Physiotherapy Reform and Physiotherapy Transition

Phase 1, 2 and 3

Central East CCAC

Our Task

• “Soft Landing” for patients • Transitioning of 4000 Patients from

Designated Physiotherapy Clinics (DPC) to CCAC

• Ensuring Service Provider human resource capacity

10

Phase I - Approach

• Initiation of a Physiotherapy Steering Committee • Seconded an Internal Physiotherapist to provide

expert advice to the steering committee • Early engagement of Service Provider Organizations

(SPO) • Early engagement of Retirement Homes (RH) and

Congregate Setting Administrators • Introduction of Physiotherapy Assistants (PTA’s)

early in the transition

11

Phase I - Approach, cont’d • Obtained patient lists from RH’s and existing

DPC providers • Assigned patients to SPO based on pre-

determined cluster care assignments • SPO assessment completed for each patient • Received recommendations from SPO

regarding patient’s transition plan – exercise and falls prevention classes – continue with restorative care (up to 8

weeks) 12

Phase I - Approach, cont’d

• Registered all patients in CHRIS • Authorized services based on the SPO

recommendation

13

Phase I - Results, cont’d

Physiotherapy Reform Statistics • 3972 patients received from the DPCs and

registered with CECCAC • 3290 patients received treatment from

CECCAC • 2270 referrals to exercise and Falls

Prevention Programs • 104 patients removed from Physiotherapy

waitlist

14

Phase I - Results

15

Who Did We Serve? – PT Reform Patient Age Distribution

Phase I - Results, cont’d

16

Who Did We Serve? PT Reform Profile (Existing CECCAC Patients) – Client Care Model Distribution

Phase I - What We Spent – Physiotherapy Reform

• Weekly spend peaked w/o September 16 ’13 – at $137,679 – Total 3972 Patients

17

Phase II - SPO Engagement • Utilizing data from Phase I

– What is the future going to look like – Service Levels

• Agreement by all SPO to utilize standardize assessment tools – Functional Assessment Matrix was

developed • 3 restorative streams based on functional

abilities assessments

18

Phase II - Community Based Assessment Measures

• Gait – Timed Up and Go (TUG) – 50 Ft Walking Test – Dynamic Gait

• Pain – Visual Analog Scale (VAS)

• Strength – Manual Muscle Testing

19

Phase II - Community Based Assessment Measures cont’d

• Balance – Functional Reach – BERG – Tinetti

• Other – Elderly Mobility Scale (EMS) – Disabilities of the Arm, Shoulder and Hand

(DASH) – Barthel – Physical Performance Test (PPT)

20

Phase II - Initial Restorative Streams

• Stream A – Up to 12 Weeks – 3 PT/9PTA visits

• CHRIS Stream 2 • Stream B – up to 24 weeks

– 7 PT/17 PTA • CHRIS Stream 3A/B

• Stream C – up to 32 weeks – 10 PT/25 PTA

• CHRIS Stream 3A/B 21

Phase II - Functional Indicators (FI) Chart

22

Phase II - What We Spent - Transition

• Weekly spend peaked w/o December 16 ’13 – at $18K – Total 420 Patients (298 Maintain, 122 Restore)

23

Phase II - Lessons Learned

• Most patients did not require the full 32 weeks of service to meet their goals

• Physiotherapists were not utilizing all of the assessment tools

• Outcomes collected in existing Care Coordinator assessment tools need to be aligned with the new physiotherapy model

24

Phase II – Refining the Model • Reduced the number of measurement

tools used from 12 to 8 – TUG, Dynamic Gait – VAS – Berg, Tinetti – MMT – EMS, DASH

• Aligned the streams with the Provincial restorative streams

25

Phase III - Updated FI Chart Gait Pain Balance Strength Other

Self Management Goal (Patient’s own goal)

Tool Options

• TUG • Dynamic Gait

• VAS (Visual Analog Scale)

• Berg • Tinetti/Gait

• MMT (Manual Muscle Testing)

• Elderly Mobility Scale • DASH (Disabilities of

the Arm, Shoulder and Hand)

PT Stream 2 Restore to Optimal Up to 16 weeks (1 assessment + 6PT/12PTA)

TUG: 20-29 ____ Dynamic Gait: 14-16 ____

VAS: 1-5 ____

Berg: 29-56 ____ Tinetti/Gait: greater than or equal to 22+ ____

MMT: 3-5 ____

Elderly Mobility Scale: 12+ ____ DASH: 20-49 ____

PT Stream 3 A) Maintain

PT/PTA Up to 24 weeks (1 assessment + 8PT/22PTA) A) Maintain

PT/PSW (requires PSW service already in place)

Up to 24 weeks (1 assessment + 8PT/17PTA)

TUG: 30+ ____ Dynamic Gait: 13 or lower ____

VAS: 6-10 ____

Berg: 28 or lower ____ Tinetti/Gait: 21 or less ____

MMT: 1-2 ____

Elderly Mobility Scale: Under 11 or less ____ DASH: 50+ _____

26

Phase III – Refining the Model

27

Process For Admitting New Patients

Phase III - Restorative Physiotherapy Eligibility - RAI HC

28

Phase III - What We Spent – Physiotherapy Streams

• Includes All PT streams • Weekly spend peaked w/o March 03 ’14

– At $44,326 29

Phase III - Total Spend

30

Phase III – Lessons Learned • CECCAC evaluated the sustainability of the

Phase III Model • Significant financial pressure to meet the

2014-15 target of 6664 additional patients within our budget

• PT/PTA is a viable model for community based therapy service

• The change from “acute” to “restorative model” of care is a lengthy process for care coordinators and service providers alike

31

Phase III (IV) • In collaboration with our SPO we are refining

our eligibility criteria • Stream 2 eligibility

– Post acute physiotherapy – Stroke, risk for falls – 2 Physiotherapists and 6 PTA visits

• Stream 3B – 2 Physiotherapist visits to assess for PSW

supported activation/maintenance

32

Personal Support Services (PSS) Organization Engagement –

Stream 3B • Invited our PSS organizations to assist with

the development of the activation program • Physiotherapy agencies agreed to develop a

standing and sitting activation program appropriate for Personal Support Worker (PSW) supervision

• Transfer vs delegation of care to PSW

33

Next Steps

• Finalize the standing and sitting activation program

• Re-educate Care Coordinators and SPO in the new program

• Set up train the trainer modules for sustainability

34

Questions

35

Implementing the New Physiotherapy Model: Successes, Challenges & Key

Learnings

Carey Lucki Mississauga Halton CCAC

36

Mississauga Halton CCAC • Ontario’s 4th largest CCAC • Serve more than 41,000 patients annually

(2012/2013 data) • 2nd fastest growing population of seniors in

Canada (projected 32.2% increase in seniors aged 75-84; 71% increase in seniors aged 85+)

• Highly diverse area (43.2% cultural diversity)

• One of Canada’s fastest growing populations (15% by 2014)

37


Mississauga Halton CCAC Serve the municipalities of

south Etobicoke, Halton Hills, Mississauga, Oakville and Milton.

Over 1.1 million people in the region.

We cover ~ 900 square kilometers with a mix of urban/rural composition.

38


Strategic Plan


Quality Community Care Outcomes Focused Patient Care

Implementing and sustaining the necessary

infrastructure, processes, care models and practices to ensure the delivery of safe, effective, evidence-based

and high-quality care to every patient, every day.

Rehabilitation Programming

MH CCAC Rehabilitation Initiatives


Physiotherapy Model of Care (POC) November 2013

Home Independence Program December 2013

Rapid Recovery January 2014

Hips/Knees OBPs/Regional Work February 2014

Stroke Program April 2014

PT Reform Transition of

5400 patients August 2013

Phase 1 Launch of PT

Model Mid November

2013

Phase 2 Launch of PT

Model April 2013

? Query Phase 3 Fall 2014

41

Org wide All streams All SPOs

(4+ months) Data collection/Metrics

Focus Groups – Care Coordinators/SPOs Other POC sites, external stakeholders


PT Journey

Physiotherapy New Streams of Care

Mississauga Halton CCAC 42

Stream 1 Improve and Rehabilitate to

Independent Function

Stream 2 Assess and Restore Optimal

Function (slower stream rehab)

Stream 3 A/B Maintain and Prevent Decline in

Function

Org wide All streams All SPOs

43


Phase 1

Revised January 20th, 2014 MH CCAC

↓ ↓

↓ or ↓

0 – 90 days LOS (3 months) Up to 12 PT visits

It is expected that PT goals are met in Stream 1. If client is slow and/or not progressing

towards goal achievement, consider moving to Stream 3

0 – 60 Days LOS (2 months) PT and PTA visits

*PTA cannot be entered in CHRIS; enter all visits as PT in CHRIS

0-14 days (2 – 3 PT visits)

CSR completed by SPO

-Assessment (goals, teaching,

self-management) -Expected LOS

-Identification of other service

needs

15 – 60 days (3 – 6 PT visits)

D/C or progress

to Interval 3

61 – 90 days (2 - 3 PT visits)

D/C or consider

Stream 3

0-60 days

3-4 PT visits as required to monitor progress *CC has

discretion to add more PT if necessary*

1 - 3 PTA visits per week D/C or consider Stream 3 if

necessary

9 – 10 month LOS

PT and PTA visits or

PT and PSW (training to supervisor)

*PTA cannot be entered in CHRIS; enter all visits as PT in CHRIS

Up to 3-4 PT visits as required to train PTA and

monitor progress *CC has discretion to add

more PT if necessary*

1-2 PTA visits per week

Up to 3-4 PT visits as required to train and monitor progress

*CC has discretion to add more PT if necessary*

Add PSW time as follows: For cluster care sites, add additional units 15 or 30 mins (Enter as 1.25 or 1.50 in CHRIS)

For in home - Care coordinator has discretion to allow 30 mins -1 hour extra PSW per week to accommodate PT programme. Alternatively, it can be built into existing PSW allotment.

Tip: PTA or PSW?

PTA: Focused intervention. May involve specific stretching, more complicated exercises, some modalities (i.e., accutens)

PSW: Exercises are maintenance in nature, easily incorporated into the care plan. Gentle movement, ROM or walking small distances.

Comparison Physiotherapy Previous Model New Model Length of Stay 3-4 weeks 12 - 40 weeks Visits 2 or 3 visits 8 – 24+ visits Service Plan Assessment

Consultation Assessment Treatment Consultation

Use of other services

PT PT/PSW

PT/PTA PT/PSW

Discharge Disposition

Goals met Goals met

Type of Service Generic Specific to population/need

44


Key Assumptions Patients would begin at Stream 1 and progress through subsequent

streams if required Physiotherapists would determine total number of visits required

and length of stay Physiotherapists would identify the need for PTA involvement and

provide oversight and direction as to PTA service Physiotherapists would continue to work with PSW as in traditional

models; PSWs could now begin exercise programming as part of their care plans

45


Metrics November 2013 – March 2014

Units per patient Stream 1 3.5 – 3.9 Stream 2 4.8 Stream 3A 7.5 Stream 3B 2.9 Average 4.0

Length of stay Stream 1 30.25 days Stream 2 31.25 days Stream 3A 26.25 days Stream 3B 37 days Average 31.19 days

Stream distribution Stream 1 53% Stream 2 30% Stream 3A 12% Stream 3B 5%

46


Metrics

2012 - 2013 2013-2014 # of patients 5,082 7,537 Cost per patient $455.96

$392.62

Units 21,139 30,320 Units per patient 4.2 4.0 Length of stay

30 days 31.19 days

47


Findings Beginning all patients in Stream 1 did not always correlate with

patient need and ‘right care’ PT utilization did not change significantly (remained at 4 units per

patient on average) Transition from 2-3 visit consultation model to a broader, expanded

role of PT which focuses on establishing SMART goals and the provision of treatment over a longer period of time

PSW incorporation of exercise programming PSW allocation Prescriptive PT/PTA visits did not always correlate with patient need

and ‘right care’ PT/PTA ‘new’ relationships

48


November – February 2014

49

100

0

83

17

41

59

PT PTA PT PTA PT PTA

PT1 PT2 PT3A

PT/PTA Breakdown


Challenges • Competing demands (Accreditation, DMS, other rehab programs) • Unforeseen events (Red Cross Strike) • Holidays • Hospital surges • Referral Coding

50


Successes The benefits to our patients with these PT Streams is immeasurable if

it allows patients to be more active and safer in their home and community, and for some it allows them to stay in their home rather than have to contemplate a move to a RH or LTCF.

I like the structure of each stream, goal expectations are known, it is

not restrictive in length, clients could start in Stream 1 and progress through to Stream 2 or 3 if as per PT professional judgment/discussion with CCAC that, ongoing therapy would benefit patient. I also like that the frequency authorization is standard for all Access ordering the service, because it equalizes services for all, rather than I think they should receive 2 visits and some other Access CCs think 1 visit is enough.

51


Phase 2 - Changes Model/framework remained the same Reinforced use of the RAI-CA rehab algorithm at intake CC chooses stream; subject to change based on initial clinical PT

assessment Visit frequency/length of stay was modified Removed the prescriptive PT/PTA visit specifications Revised the PT/PSW service plan Revised the PSR/CSR Reinforced the use of SMART goals Implemented the reporting of clinical outcome measures – pre/post

test scores

52


53

MH CCAC Physiotherapy Streams Guideline

Description Stream 1 Rehabilitate to Independence

Stream 2 Restore to

Optimal

Stream 3A Maintain & Prevent

Decline

Stream 3B Maintain & Prevent

Decline CHRIS Referral Code PT1 Rehab to Independence PT2 Restore to Optimal PT3A Maintain PT/PTA PT3B Maintain PT/PSW

Clinical Presentation

Patients who have a specific, focused need and predictable treatment/rehabilitation

journey

Patients who may have a specific, focused need and

predictable treatment/rehabilitation

journey but will take longer to meet goals (slower stream

rehab)

Patients who present with acute or chronic gait deficit, balance

deficit, reduced functional strength resulting in functional

decline in ability to perform ADLs

Patients who present with acute or chronic gait deficit, balance

deficit, reduced functional strength resulting in functional

decline in ability to perform ADLs

Eligibility Criteria Specific, focused assessment and treatment in the following areas:

• Orthopaedic (fractures) • Neurological (MS, Parkinson’s) • Respiratory (COPD) • Musculoskeletal/Exercise (post-

surgery, post injury/fall) EXCLUSION:

• OBP hips/knees • Stroke program • Rapid Recovery

• Generally – slower stream rehabilitation

• Frail, older adults • Functional loss is

reversible (capacity to improve)

• 2 or more co-morbidities with complicating factors

• 2 or more falls in last 6 months

• Decline in ability to independently perform 1 or more ADLs in last 6 months

• Deconditioning (as a result of hospital stay or exacerbation of a chronic condition)

• Need to prevent further decline

PTA criteria: -patient is expected to have ongoing changes but condition is stable and pain is controlled -PT is delegating program to PTA and continuing to supervise the PTA -evidence based program is recommended and expected to be stable over a period of time (3 wks)

• 2 or more co-morbidities with complicating factors

• 2 or more falls in last 6 months

• Decline in ability to independently perform 1 or more ADLs in last 6 months

• Deconditioning (as a result of hospital stay or exacerbation of a chronic condition)

• Need to prevent further decline

PSW criteria: -patient is stable, not changing, long term mtce -PSW may be doing a walking program -recommendations from PT are not required on an ongoing basis -PT transfers skill to PS Supervisor/PSW -PT will discharge once skills are transferred


ACCESS – At A Glance

54

CC determines eligibility for CCAC physiotherapy service

RAI-CA is completed. Rehab algorithm is calculated (see below, next page)

Rehab algorithm score is 1-2 Patient can safely attend an outpatient

class or program without hardship

RAI – CA rehab algorithm score is 3+ Determine PT Stream based on algorithm and clinical judgement. Assign

referral to SPO. Add referral code in CHRIS

Refer to outpatient PT, falls prevention, exercise classes,

clinics

*if classes cannot accommodate patient due to wait listing, place

on Stream 1

YES

NO

Stream 1

Referral Code: PT1 Rehab to Independence

RAI-CA rehab algorithm = 3 SRC = 92 Service Plan: Block of 8 PT visits

LOS: 8 weeks

PT will likely discharge after 8 weeks

Stream 2

Referral Code: PT2 Restore to Optimal

RAI-CA rehab algorithm = 4 SRC = 93 Service Plan: Block of 12 PT visits (combination of PT/PTA - PT will determine

how much PTA) LOS: 8 weeks

PT will need to revise PED after 8 weeks with community CC.

Stream 3A

Referral Code: PT3A Maintain & Prevent

RAI-CA rehab algorithm = 4/5 SRC = 93/94 Service Plan: Block of 12 PT visits (combination of PT/PTA – PT will determine how much PTA)

LOS: 8 weeks

PT will need to revise PED after 8 weeks with community CC.

Stream 3B

Referral Code: PT3B Maintain & Prevent

RAI-CA rehab algorithm = 4/5 SRC = 93/94 Service Plan: Block of 4 PT visits (combination of PT/PSW) PT will determine if PSW can be used for exercise programming and communicate with Community CC. LOS: 8 weeks. PT will need to revise PED after 8 weeks with community CC and/or discharge.


Successes • Bi weekly meetings with 4 contracted rehab SPO agencies “Best Practice Rehabilitation Committee” • Frontline CC roadshows and team meetings • Identified Care Coordinator ‘rehab’ champions per team • THP/HHS/CVH road shows – allied health and patient

navigators/discharge planners • Formed a outcome based metrics committee to further inform:

% patients per stream Cost/utilization Clinical outcome measures Patient satisfaction Discharge disposition – referral to exercise classes/falls

prevention classes, CSS • Intranet

55


PT Models of Care

56

Where are we? • Phase 2 launch – April 2014 • Change management curve is moving upwards with acceptance,

experimentation, and integration • Costs are on the rise ~ 21% more per month • Stream breakdown:

Stream 1 30% Stream 2 46% Stream 3A 10% Stream 3B 14%

• Clinical outcome measures - too early to analyze • Metrics analysis • PSW engagement

57


Questions

Mississauga Halton CCAC 58

Central West CCAC

Physiotherapy and Exercise and Falls Prevention Program

Kimberley Floyd

Central West CCAC

June 9, 2014

Overall Vision:

To Develop a Sustainable Physiotherapy / Exercise and Falls Prevention Program

in the Central West Region

Execution of PT Reform in Central

West LHIN • Allowing for continuity of care between in-home physiotherapy

and exercise and falls prevention with CCAC implementing and overseeing both streams

• Developing a flexible, streamlined and innovative delivery model that blends exercise and falls prevention classes to optimize available resources and maximize outreach to seniors

Physiotherapy Continuum

• Consistent service provider treats patient within neighbourhood

approach to care (congregate setting and in home/community settings)

• Patient progresses through streams that meet their presenting needs within safe and effective transition between streams with no gaps in service or redundancy in assessments and treatment

• Execution of recommended PT streams across all service providers supported by exercise and falls prevention classes as an extension of any one on one in home stream

• Care offered across continuum close to home in neighbourhood locations across the LHIN

Exercise and Falls Prevention Classes

• Implementing a combined Exercise and Falls Prevention education service delivery model

• Ensuring continuity of care

• Optimizing available resources and maximizing outreach to seniors through innovative model of care

• All classes are replicated in congregate and community settings including specialized classes sensitive to community needs (mental health, culture and disease specific)

Exercise and Falls Prevention Model

• Each class has a blended approach of exercise and falls prevention built into every class

• Classes run 48 weeks a year • Overseen by regulated health care professional • PTA runs the class under a supervision model by the PT • Congregate settings and Community Based classes are supported

by this model • Building of strong community partnerships for community sites

including Recreation and Parks departments, municipalities, primary care practices and other community settings

• Self management and chronic disease management education components built in through interprofessional team based organized sessions

Commitments of PT Model

• Committed presence of therapy team in congregate settings to integrate into the inter-professional team

• Consistent team of therapists working within each congregate setting

• Provide a continuum of care with in home Physiotherapy and exercise and falls prevention classes with PT and PTA model

• Communication/documentation within congregate settings • Support in falls prevention programs in Retirement Homes as per

Retirement Home Act • Timeliness of interventions (reduce waste in the process or

unnecessary bureaucratic steps) • Main elements of model replicated across all locations • Model transferable to in home focus

Lessons Learned

• Communication: Process is required for weekly established meetings between PT care team and

Retirement Home PT and PTA of class and in home therapy must be supported to case conference

• Oversight:

Supervision Model is imperative between PT and PTA PT needs to have professional accountability for whole model Appropriate compensation must be offered to support program oversight,

supervision, care planning and participation in falls prevention programming Standardizing quality metrics across continuum that is evidenced based

• Intake Process:

Needs to be seamless and real time Encourage therapist and congregate setting to forward a referral and then

receive immediate authorization to assess patient (supports transition from hospital to home as one example)

Logistics • Screening Processes to recommend class best suited to the needs

of the senior and to support service outcomes by regulated health care professional

• Seniors registered in desired classes (location and time convenience) in order to maximize consistent attendance in classes

• Attendance monitored for all class settings (congregate and community locations in order to provide CSS sector statistics)

• Care Coordinators attached to congregate and community sites as points of contact and patient level care planning and system navigation

• Strengthened collaborative care planning that extends beyond PT reform (proactive service planning opportunities)

Five Pillars of Ideal Continuum of Care

Continuity of Care Team

(PT, PTA and Care Coordinator)

Proactive Communication Approaches in

Congregate Settings

PT and PTA Integrated into Care Team in Congregate

Setting

Documentation Practices that

Support Interprofessional Care Planning

Seamless and Timely Access to

Service

Retirement Home Partnership

• Collaborative service planning around falls prevention which includes monitoring and reporting of falls

• Informing program design

• Commitment of regular engagement re refinement of model

• Established planning days to ensure development of quality outcomes

• Satisfaction of model is continually explored based on the above practices

• CCAC Managers aligned with all congregate settings in order to escalate any issues in real time

Benefits

• Seniors are navigated to appropriate health services by leveraging existing system structure of CCAC

• Utilize centralized function to implementation and navigation that ensures efficiencies and better quality in providing services and monitoring of service providers

• One stop source of information for program options for seniors and other stakeholders

• Reduced delay in access to services

Benefits Continued

• Individualized plan of care for seniors involved in services from a care team who is proactively meeting their needs

• Preventative approach to educating on the multi factoral elements of falls prevention by leveraging use of interprofessional resources in neighbourhoods

• Evaluation and outcome measurement is strengthened as a critical mass of locations exist with a consistent approach to the model of care

• Sharing of best practices to create a Community of Practice among providers in Central West LHIN

Questions

Kimberley Floyd Director of Client Services, Central West CCAC

905-796-0040 ext. 7705 [email protected]

For More Information Laszlo Cifra

Program Director, Integrated Care, CE CCAC 416 750 2444 x 5558

[email protected]

Michelle Nurse Director, Contracts and Relationships, CE CCAC

905 430 3308 x 5247 [email protected]

Carey Lucki Program Manager, Patient Care, MH CCAC

905-403-5354 [email protected]

Kimberley Floyd Director of Client Services, Central West CCAC

905-796-0040 ext. 7705 [email protected]

expanding patient-centred in-home physiotherapy …hssontario.ca/who/conference/documents/june 9,...

Documents