Rehabilitation and Complex Continuing Care Capacity Plan

North West LHIN

Rehabilitation and Complex Continuing Care Capacity Plan May 2017

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Table of Contents

....................................................................................................................................................................................... 1

Acronym List ............................................................................................................................................... 6

Executive Summary .................................................................................................................................... 7

Background .................................................................................................................................................................... 7

Goal ............................................................................................................................................................................... 7

Alignment ...................................................................................................................................................................... 7

Methodology .................................................................................................................................................................. 8

Findings ......................................................................................................................................................................... 8

Desired Future State ...................................................................................................................................................... 9

Recommendations ....................................................................................................................................................... 12

Conclusions ................................................................................................................................................ 18

Background and Context ......................................................................................................................... 19

Project Rationale.......................................................................................................................................................... 19

Goal ............................................................................................................................................................................. 20

Alignment with Regional and Provincial Priorities ..................................................................................................... 20

Methodology ................................................................................................................................................................ 22

Limitations ................................................................................................................................................................... 25

Current State Analysis ............................................................................................................................. 26

Demographics, Population Characteristics, Health Status and Behavioural Factors ................................................... 26

Inpatient Rehabilitation ............................................................................................................................................... 30

Recommendation #1: ................................................................................................................................................... 35

Strengths, Gaps, and Recommendations ...................................................................................................................... 48

Recommendation #4: ................................................................................................................................................... 49

http://portal.lhins.on.ca/nw/operations/programs/LHINSpecific/Rehab%20Restructuring/Rehab%20CCC%20Review/Report/Final/FINAL_Rehab_CCC_Capacity_Planning_Report_LHIN_VI.docx#_Toc484182018


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Recommendation #3: ................................................................................................................................................... 49

Recommendation #2: ................................................................................................................................................... 49

Recommendation #2: ................................................................................................................................................... 52

Recommendation #4: ................................................................................................................................................... 61

Recommendation #2: ................................................................................................................................................... 61

Recommendation #3: ................................................................................................................................................... 61

Outpatient and Community Services ........................................................................................................................... 61

Recommendation #5: ................................................................................................................................................... 65

Health Human Resources ............................................................................................................................................ 85

Special Consideration for Northern and Remote Issues in North West LHIN ............................................................ 86

Desired Future State ................................................................................................................................. 91

Regional Rehabilitative Care Lead Organization ........................................................................................................ 93

Care Streams ................................................................................................................................................................ 96

Flexible Inpatient Beds at the DHC and LHH Levels ............................................................................................... 102

Use of Technology in Care Provision ........................................................................................................................ 103

Remote North Access to Care .................................................................................................................................... 105

Francophone Access to Care ..................................................................................................................................... 107

Performance Measurement ........................................................................................................................................ 107

Recommendations ................................................................................................................................... 108

Next Steps ................................................................................................................................................ 114

Stakeholder Engagement ........................................................................................................................................... 114

Timelines ................................................................................................................................................................... 115

Conclusions .............................................................................................................................................. 117

Works Cited ............................................................................................................................................. 118

Appendix A – Rehabilitative Care Alliance Bedded Levels of Rehabilitative Care Definitions Framework ........... 124

Appendix B – Rehabilitative Care Alliance: Definitions for Community-Based Levels of Rehabilitative Care ...... 137

Appendix C – Rehabilitative Care Alliance Capacity Planning Framework ............................................................. 146








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Appendix D – Rehabilitation Care Alliance Planning Considerations for Reclassification of Rehabilitation/CCC

beds ............................................................................................................................................................................ 147

Appendix D – Project Charter ................................................................................................................................... 148

Appendix E – Project Roles and Responsibilities ...................................................................................................... 193

Appendix F – Operationalization and Impact of RCA Deliverables ......................................................................... 196

Appendix G – Methodology Quantitative Data Sources ........................................................................................... 197

Appendix H – Physical Rehabilitation Advisory Committee Rehabilitative Care Review Guiding Principles ........ 198

Appendix I – Community Engagement Stakeholders ................................................................................................ 206

Appendix J – RCA Bedded Levels of Rehabilitative Care Mapping Tool ................................................................ 207

Appendix K – RCA Community-Based Levels of Rehabilitative Care Mapping Tool ............................................. 208

Appendix L – System Strengths and Gaps ................................................................................................................ 209

Appendix M – Regional Population breakdowns by IDN: ........................................................................................ 217

Appendix M – Current Estimated Beds ..................................................................................................................... 219

Appendix N – Hip Fracture Process Map .................................................................................................................. 220

Appendix O – North Western Ontario Community Physiotherapy Referral Decision Tree ...................................... 221

Appendix P – Rehabilitation Resources in the North West LHIN ............................................................................. 222

Appendix Q – Geriatric Assessment & Rehabilitative Care Stream .......................................................................... 225

Appendix R – Stroke/Neuro Care Stream .................................................................................................................. 227

Appendix S – Musculoskeletal Care Stream ............................................................................................................. 229

Appendix T – Medically Complex Care Stream........................................................................................................ 231

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Acronym List

Acronym Meaning

ALC Alternative Level of Care

AR Activation/Restoration

CCAC Community Care Access Center

CCB Convalescent Care Bed

CCC Complex Continuing Care

CCRS Continuing Care Reporting System

CHF Congestive Heart Failure

COPD Chronic Obstructive Pulmonary Disorder

DPC Designated Physiotherapy Clinic

EOC Episode of Care

ER Emergency Room

FIM Functional Independence Measure

FTE Full Time Equivalent

HBAM Health Based Allocation Model

HCCP Home and Community Care Program

IDN Integrated District Network

IHCO Integrated Health Care Organization

IHSP Integrated Health Service Plan

ISAEC IntraSpinal Assessment and Education Centre

LHH Local Health Hub

LHIN Local Health Integration Network

LOS Length of Stay

LTC Long Term Care

MOH Ministry of Health

MOHLTC Ministry of Health and Long-Term Care

MOST Moving on After Stroke

MSK Musculoskeletal

NIHB Non-Insured Health Benefits

NP Nurse Practitioner

NRS National Rehabilitation Reporting System

NWO North Western Ontario

OT Occupational Therapist

OTN Ontario Telemedicine Network

PCVC Personal Computer Virtual Conferencing

PRAC Physical Rehabilitation Advisory Committee

PSW Personal Support Worker

PT Physiotherapist

QBP Quality Based Procedures

RCA Rehabilitative Care Alliance

RJAC Regional Joint Assessment Center

SJCG St. Joseph’s Care Group

SJH St. Joseph’s Hospital

SLP Speech and Language Pathologist

SW Social Worker

TBRHSC Thunder Bay Regional Health Sciences Center

VON Victoria Order of Nurses

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Executive Summary

Background

Rehabilitative care is defined as “a broad range of interventions that result in the improved physical,

mental and social wellbeing of those suffering from injury, illness or chronic disease.” The importance of

rehabilitation within the global context of healthcare has been well documented. In light of the ongoing

changes and increased demand placed on the healthcare system, it has become increasingly important to

identify optimal care practices and efficiencies. In the North West Local Health Integration Network

(LHIN), the above average burden of chronic diseases and musculoskeletal disorders, combined with a

widely dispersed population, present a unique challenge to providing equitable access to high quality

rehabilitative care. In order to meet this challenge, the North West LHIN is committed to ensuring all

aspects of rehabilitative care within the region are delivered within an integrated system, including care

provided as close to home as possible. In 2014, the LHIN initiated a capacity-planning project to create an

integrated model of rehabilitative care for the North West LHIN.

The following plan represents a culmination of this work and presents recommendations to support an

integrated service delivery model of inpatient and outpatient rehabilitative care services for the residents

of Northwestern Ontario (NWO). The term rehabilitation is used throughout this report and is inclusive of

complex continuing care (CCC).

Goal

To examine the current state of rehabilitative care services and develop a future state model of

rehabilitative care in NWO to improve access to safe, comprehensive and high quality rehabilitative care

for all residents of NWO.

Alignment

All recommendations and strategic directions contained within this report are consistent and aligned with

strategy at the provincial and LHIN level. Provincially, the plan aligns with Patients First: Action Plan

for Health Care, the recommendations from the 2013 Annual Report from the Ontario Auditor General

for Provincial Standardization of Rehabilitative Care, Ontario’s Seniors Strategy, as well as Health

System Funding Reform initiatives including Quality Based Procedure (QBP) implementation. Locally,

the plan aligns with the North West LHIN Strategic Directions, Integrated Health Service Plan (IHSP)

2016-2019, and Health Services Blueprint. The proposed model is based on the North West LHIN Health

Services Blueprint recommendations of a model of services and care delivered at the local, district and

regional levels, specifically known as the Local Health Hub (LHH), Integrated District Network (IDN) or

LHIN sub-region, and Regional or LHIN-wide levels.

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Throughout this capacity-planning exercise, tools developed by the Rehabilitative Care Alliance (RCA)

were utilized to ensure the review process and all recommendations support the ongoing efforts to

increase standardization of rehabilitative care in Ontario.

Methodology

The North West LHIN Rehabilitative Care Capacity Plan and integrated service delivery model

recommendations and actions plans were created through the analysis and synthesis of qualitative and

quantitative information. In addition, extensive community engagement was conducted with key

stakeholders throughout the North West LHIN including health service providers, administrators, clients,

and families. Finally, a literature review and consultations with subject matter experts and a number of

other LHINs was conducted.

The RCA capacity-planning framework formed the foundation of this review. This framework guided the

evaluation of bedded levels of rehabilitative care, community/ambulatory care, and bedded, long stays

services. An evaluation of acute care was not included in the scope of this review and is only discussed in

relation to the demand and provision of inpatient rehabilitative care.

Findings

This review provides current data for populations receiving and requiring rehabilitative care, the available

resources within each local LHH and, to a more limited extent, the ability to access and receive care.

The following strengths and gaps were identified in the current system of rehabilitative care in the North

West LHIN:

Strengths Gaps

• High degree of satisfaction with rehabilitation

services throughout NWO and appreciation of

the services available in their home

communities by clients and families

• Existing provincial (Rehabilitation Care

Alliance) and regional networks (Regional

Stroke Network and Regional Orthopaedic

program) with common “mandates”

• Access to specialized services within the

region

• Health service providers (HSPs) willing to

work together; informal collaboration is key

tenet of providing care in the North West

LHIN

• Rehabilitation care experts willing to provide

consultation and support to providers across

the region and across disciplines

• Lack of a regional approach to rehabilitative

care planning and delivery in the North West

LHIN making it difficult to coordinate care

across settings and communities

• Variability in the availability of rehabilitative

care at the LHH and IDN levels (ie. OT, SLP

and SW); timely access to care is a challenge

• Limited access to ongoing clinical education,

experiential learning, and mentorship for

providers at all levels of care, *especially for

support workers in Aboriginal communities

• Individuals who may benefit from a

rehabilitative approach to care are not able to

consistently access the appropriate level of

care

• Timely access to home safety and equipment

assessments

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• Providers from all disciplines and care

settings desire to enhance capacity to deliver

rehabilitative care closer to home through

participation in ongoing education, skill

development, and using innovative

technologies to facilitate communication,

education, and increased access to care.

• Many existing programs can be leveraged to

support individuals and caregivers in the

community

• Existing, extensive secure videoconference

and Personal Computer Virtual Conferencing

(PCVC) infrastructure and processes in place

in the North West LHIN

• Willingness to explore partnerships to assist

with service provision, and human resource

recruitment and retention

• Limited supportive housing and social

supports throughout the region

• Lack of communication, shared medical

record and coordination at times of transition

along the care continuum, especially between

Aboriginal community providers and other

health care services; Family Health Teams

and hospital services; and between hospitals

and Community Care Access Centre

contracted service providers

• There is a loss of rehabilitation education at

the graduate level locally in NWO, through

partnerships with NOSM and McMaster

which will potentially impact recruitment and

retention

• Limited monitoring, reporting, and evaluation

of outpatient rehabilitation activities and

services at the system level

Desired Future State

The vision for NWO is to create an integrated system of care across the full continuum, from inpatient

rehabilitation to outpatient rehabilitation and reintegration to the community, which will serve all

individuals who could benefit from rehabilitative care. Regardless of the care setting, individuals will

receive care that is client-centred, sensitive to diversity and culture, delivered by an interprofessional

team, and close to home.

Within an integrated model of care, healthcare providers across the region will work together to organize

services and the delivery of care across the 14 LHHs and 5 IDNs, including specialized regional

programs, which serve all of NWO. This model has been developed in alignment with the North West

LHIN health services delivery model; within existing resources; building on the existing strengths of the

current system; and addressing the gaps in care delivery identified within the current state analysis.

The future state model will include the following key elements: a Rehabilitative Care Lead Organization,

Regional Rehabilitative Care Streams, flexibility in local LHHs to meet care needs, partnerships with the

LHHs and Integrated Health Care Organizations (IHCO), identification of specialized regional programs,

and improved regional access to all rehabilitative care services.

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The Regional Rehabilitation Program is structured with two objectives in mind:

1. Leading regional level initiatives that will result in a standardized, evidenced-based, integrated approach to care across NWO.

2. Supporting work at the IDN, LHH, and HSP levels to implement best practices and deliver

standardized rehabilitative care programs and services to all populations across the North West

LHIN.

The Rehabilitative Care Lead Organization will provide the required leadership for coordination and

planning, monitoring and evaluation, evidence-based practice knowledge translation, communication,

education, research, capacity-building, and advocacy, over and above actual service delivery. Each Care

Stream will have identified leaders as consistent contacts and knowledge exchange experts for a specific

area of rehabilitation, and teams of rehabilitation professionals who will be available to provide

assessments and consultation with regional providers as required. Under the guidance of the Regional

Program, community facilitators will be identified at the LHH or IDN level to lead the development of

rehabilitative care in every LHH. The Rehabilitative Care Lead organization, Care Stream Leads, and

community facilitators will provide leadership to implement recommendations from the Regional

Program at the LHH level.

Based on RCA bedded levels of rehabilitative care definitions, existing care pathways, and client care

needs, the following care streams will meet the specialized care needs of NWO:

• Geriatric Assessment and Rehabilitative Care.

• Specialized Rehabilitation (Neurological, Stroke; Orthopaedic and Musculoskeletal) Services

Stream.

• Medically Complex Services (Wound, Lymphedema, Pulmonary, and Chronic Disease).

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The following figure depicts the structure of this integrated system.

North West LHIN Regional Rehabilitative Care Program - Integrated Systems of Care

The model aims to coordinate rehabilitation services across the region by leveraging existing services and

expertise from a larger regional centre with more specialized and comprehensive services, to enhance and

support existing services in each smaller, remote community where population, economies of scale,

recruitment, and retention do not support the same level of care. Collaboration between specialized

rehabilitative care services delivered at the regional level and rehabilitative care delivered at the LHH will

ensure client needs are met as close to home as possible. This model will promote improved access and

better transitions in care by encouraging integration within each level, and across all levels of care. The

overall goal of an integrated system is to provide excellence in care, built on a vision of improved access

and flow, standardization, coordination, and the use of evidence-based care to improve the client journey.

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Care Stream Model

To support clinical service delivery, the care streams will have a knowledge exchange strategy. This

knowledge exchange strategy will be supported by the Regional Rehabilitative Care Lead organization

and will include the following: identified clinical and specialist physician leads, an accessible website,

and an annual retreat. The identified leaders will be a consistent contact and knowledge exchange expert

for clinicians throughout the region.

It is expected the outcomes of the Regional Rehabilitative Care Program include improved access to the

most appropriate standardized level of rehabilitative care for clients as close to home as possible,

improved transitions for each client with improved communication among the care teams, increased

access to best practice and QBP recommendations for all clients and clinicians, and a clear care path for

every client who requires rehabilitation in the North West LHIN.

Recommendations

The following recommendations will support the development and transition to an integrated model of

rehabilitative care creating a more accessible, efficient, effective, coordinated, and collaborative

continuum of care for residents of the North West LHIN.

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Action Items Healthcare

Level Deliverables Outcomes

Recommendation #1

Improve client experience and outcomes through the implementation of the RCA definitions framework to align rehabilitative care in the North West LHIN

with the provincial framework.

1.1 Ensure there is regional alignment

with the RCA definitions frameworks

for bedded and community-based

levels of rehabilitative care

• Provincial

• Regional

• RCA Bedded and Community Mapping

Tool results

• Full alignment with approved exceptions

• Plan for any alignment issues

1.2 Educate service providers regarding

the definitions

• Regional

• IDN

• LHH

• Education module on rehabilitative

levels of care

• Education module delivered in all

hospitals throughout North West LHIN

• Increased knowledge & understanding of

rehabilitative levels of care

1.3 Create an implementation schedule to

achieve alignment by March 2017

• LHIN

• IDN

• LHH

• Implementation Plan • Full alignment by March 31, 2017


1.4 Upon referral, establish a process to

determine the appropriate level of

rehabilitative care for each client and

the appropriate location of

rehabilitative care i.e. LHH, IDN and

the region

• Regional

• IDN

• LHH

• Care stream process map developed and

shared throughout the LHIN

• Regional Rehab referral system piloted

in 2 IDNs

• Quality, evidence-based care

• Improved access to care

• Care as close to home as possible

1.5 Confirm the required health human

resources to provide each level of care

and the capacity of each health hub

and integrated network to provide the

level of care

• LHIN • Capacity Plan • Quality, evidence-based care



1.6 Establish a process to gather

information regarding the

rehabilitative care provided by

regional hospitals on their inpatient

units

• LHIN • RCA Bedded & Community Mapping

Tool

• Completed community engagement

profile

• Regional Rehabilitation Health Human

Resources Table



• Capacity planning completed at the LHH and

IDN levels

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1.7 Maximize Convalescent Care Bed use

to align with Activation/ Restoration

Bedded Levels of Care by addressing

process issues related to barriers such

as IV medications, staffing resources,

and discharge location determination.

• LHIN

• IDN

• LHH

• Committee established between

stakeholders to identify and address

barriers

• Process map developed and shared

throughout the LHIN

• Full alignment with Activation/Restoration

Level of Care in IDNs with CCB



Recommendation #2

Develop a LHIN-wide strategy to improve client access and client transitions across the continuum of rehabilitative care.

2.1 Review current or create

appropriate diagnosis-specific

client care pathways based on best

practices to support the access and

transition between inpatient and

outpatient services across the entire

North West region

• Regional

• Care Pathways

• QBP Heat Map for stroke, TKR, THR,

Hip Fracture, COPD, CHR, etc.

• Care stream Leads established

• Appropriate LOS

• QBP optimization


• Improved client/care transitions

• Improved quality of care

• Care close to home

2.2 Develop a plan and implementation

strategy to improve transitions

between specialized rehabilitation

services and local services at either

the IDN or LHH level and

transitions home

• Regional • Discharge process map

• Discharge checklist

• Standardized documentation

• Standardized referral form across

regional/IDN/LHH

• Standardized process for accessing OT

Home visits post discharge from

hospitals

• Improved client care transitions


• Clear documentation

• Enhanced communication among providers

2.3 Improve direct access from primary

care and community care providers

to both inpatient and

outpatient/community-based

rehabilitation programs throughout

the region

• LHIN

• IDN

• LHH

• Care pathways established: community-

hospital-community

• Coordinated referral management

system for rehabilitative care

• Memorandum of agreement with FHTs

• Frail Senior/Medically Complex Care

stream Lead


• Decrease unnecessary ER/acute care visits


• Decrease ALC for LTC

• Care close to home as soon as possible

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2.4 Evaluate opportunities for the

development specialized outpatient

programs to be delivered closer to

home, building on successful

regional models

• Regional

• IDN

• LHH

• Care Stream Leads

• Specialized OP programs delivered at

IDN/LHH

• Provision of local temporary housing as

necessary




2.5 Strengthen connections between

local service providers and regional

care networks to provide support

for LHH provision of rehabilitative

care

• Regional

• IDN

• LHH

• Annual Retreat

• Care Leads

• Health Human Resources Contact List

• Enhanced communication amongst providers





2.6 Develop a mechanism to share

information regarding and access to

visiting specialists programs to

support an integrated regional

model of specialized client care

• LHIN

• FHT

• IDN

• LHH

• Visiting specialist program integration

• Care Leads/Care Streams




Recommendation #3

Facilitate adherence to best practices for rehabilitative care to improve client-centred care.

3.1 Build capacity to meet best practice

and QBP expectations at a local

level though knowledge-sharing

across the region

• Regional

• IDN

• LHH

• Annual Retreat


• Website

• Communication with Physicians

• Full QBP funding





3.2 Strengthen and expand existing

clinical practice networks for

rehabilitative care providers to

ensure an integrated model exists

across the Northwest

• Regional

• IDN

• LHH

• Annual Retreat


• Website



• Enhanced communication amongst providers



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information regarding best practices

for rehabilitative care throughout

the region (such as website and/or

care streams leads)

• Regional

• IDN

• LHH

• Annual Retreat


• Website





Recommendation #4

Enhance utilization of innovative technologies to improve access to rehabilitative care services closer to home, particularly in remote and underserviced areas.

4.1 Develop a process to support and

expand access to assessment and

treatments with regulated healthcare

providers in communities where

regulated health providers are not

available

• Regional

• IDN

• LHH

• Care Streams Leads

• Rehabilitation Training for PSWs/

Therapy Assistants

• Discharge Process Map

• Appropriate Care following Regulatory

College Standards

• Community Exercise in Far North

• Rehab in 10/39 Far North Communities







4.2 Evaluate opportunities and review

the feasibility of integration of

specialized programs delivered

using technology

• LHIN

• Regional

• One exercise program per LHH

(depending on demand)

• Efficient resource utilization

• Streamlined service delivery



4.3 Support provincial and LHIN

initiatives of a shared Electronic

Medical Record

• LHIN • Shared EMR • Improved quality of care


Recommendation #5

Develop and implement data collection and evaluation systems for quality of care monitoring and continuous quality improvement to improve resource

efficiencies for the provision of client-centred care.

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5.1 Review existing reporting

mechanisms and provide advice

regarding how to improve data

accuracy and quality to support

future decision-making regarding

rehabilitative care services.

• Provincial

• LHIN

• Adopt RCA recommendations

regarding key indicators; collect and

monitor key indicators

• OP Minimal Data Set

• Accurate quality data

• Improved decision making regarding

rehabilitative care needs

5.2 Provide training and assist in the

implementation of data collection

systems for outpatient programs to

align with RCA minimum data set

recommendations, including care

outcomes, experience and cost.

• Provincial

• Regional


regarding key indicators; collect and

monitor key indicators

• OP Minimal Data Set Tool kit

• Accurate quality data to inform decision

making

5.3 Monitor and measure overall

system performance

• Provincial

• LHIN

• Rehabilitation Score Card

• Evaluation of referral management

system


• Improved client experience


• Efficient resource use

5.4 Using RCA tools, measure the

client progress and care experience

in each rehabilitative care setting

• Provincial

• LHIN

• Regional

• Key indicator data sets • Quality, evidence-based care




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Conclusions

Implementation of the identified recommendations and action plans will result in a coordinated regional

model of rehabilitative care. The use of technology, development of care networks, and partnerships with

our remote communities will continue to enhance our care provision, and in turn assist to develop a

strong, lasting, equitable, integrated system of rehabilitative care. By building on the existing passion and

commitment to meet the unique rehabilitation needs of our clients, the integrated system will provide

excellence in care, built on a vision of improved access and flow, standardization, coordination, and the

use of evidence-based care to improve the client journey.

A Rehabilitative Care Lead Organization will be announced followed by the establishment of a

Rehabilitative Care Advisory Committee which will include regional stakeholders and participation

across all levels of rehabilitative care including client and family representation, clinician representation,

and administration representation. At the same time, Regional Rehabilitative Care Streams will be

implemented to support best practices, QBP adherence, and availability of rehabilitation for all clients

across the continuum and across the region. Each care stream will have interprofessional teams to provide

assessments, triage, and consultation with regional providers as required, as well as an identified Care

Stream Lead to facilitate knowledge exchange for clinicians and appropriate, efficient, and effective client

transitions.

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Background and Context

Project Rationale

Rehabilitative care is defined as “a broad range of interventions that result in the improved physical,

mental and social wellbeing of those suffering from injury, illness or chronic disease.” The importance of

rehabilitation within the global context of healthcare has been well documented. Rehabilitation is

“instrumental in enabling people with limitations in functioning to remain in or return to their home or

community, live independently, and to participate in education, the labour market and civic life”. In light

of the ongoing changes and increased demand placed on the healthcare system due to the aging

population, it has become increasingly important to identify optimal care practices and efficiencies. In

response to the 2013 Annual Report of the Office of the Auditor General of Ontario, the Rehabilitation

Care Alliance (RCA) was created to standardize the provision of rehabilitative services (inpatient and

outpatient) across the province, with the goal that all Ontarians can expect the same standard range of

rehabilitative services to be provided anywhere in the province, within certain geographic and population

limitations. The challenges to providing access to healthcare in NWO are long-standing: sparsely-

populated, vast geographical area; a healthcare budget which is population-focused; and attracting and

retaining qualified healthcare professionals. In recent years, the North West Local Health Integrated

Network (LHIN) has conducted ongoing evaluations of healthcare practices in order to develop a strategy

to meet changing needs.

In the North West LHIN, there is a strong demand for rehabilitative care services and the demand is

expected to increase significantly as the population continues to age. Over the next ten years, the

population aged 65 to 79 will increase by 42 percent in the region and as a result, an age-related increase

in chronicity and complexity of medical conditions. Based on these factors, it is expected there will be an

even greater demand for rehabilitation and restorative care services, prevention, and the need for

programs to support health maintenance to prevent the premature decline in health status. The term

rehabilitation is used throughout this report and is inclusive of complex continuing care (CCC).

Historically, these services were primarily based out of the City of Thunder Bay, with over 65% of the

allotted CCC bed capacity and 100% of the designated rehabilitation beds located in the City of Thunder

Bay. While these services have met the needs of many residents of Northwestern Ontario (NWO), gaps

remain within the current system, which limit access to quality rehabilitative care for some residents. As

outlined in the 2013 North West LHIN Health Services Blueprint, there is a need for integrated, post-

acute rehabilitative care, which improves client outcomes and client experiences along the entire

continuum of rehabilitative care services.

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Figure 1. The Patient Journey

In 2012-2013, a detailed review of Rehabilitation and CCC in NWO was completed to help inform the

development of the North West LHIN Health Service Blueprint. In 2014, the North West LHIN funded

St. Joseph’s Care Group (SJCG) to complete the first phase of the post-acute rehabilitative care services

review by consolidating existing information to inform future planning and this capacity-planning

exercise.

Goal

The overall goal of this plan is develop an integrated rehabilitative care model to improve access to safe,

comprehensive and high quality rehabilitative care for all residents of NWO. The plan provides a

comprehensive analysis of the current and future state needs for rehabilitative care in the North West

LHIN which when implemented will facilitate improved quality, efficiency, and cost-effectiveness with

the benefit of services delivered as close to home as possible.

Alignment with Regional and Provincial Priorities

Alignment with Provincial Priorities

The development of the North West LHIN rehabilitation capacity-planning review was informed by and

advances the strategic directions found in a number of Ministry of Health and Long-Term Care’s

(MOHLTC) and North West LHIN reports including: Patients First: Action Plan for Health Care;

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Ontario’s Seniors Strategy; Living Longer, Living Well; North West LHIN’s Health Services Blueprint:

Building our Future; as well as the Integrated Health Services Plan (IHSP) 2016-2019. All of these

reports include the themes of:

• Providing the right care, at the right time, in the right place, as close to home as possible.

• Delivering coordinated and integrated care in the community.

• Ensuring access to the same high-quality standard of care for all.

• Providing care as close to home as possible.

• Promoting use of evidence-based solutions and continuous quality improvement.

• Increasing the use of virtual care tools and innovative approaches to care.

• Increasing the utilization of the most appropriate resource through interprofessional care teams.

• Enhancing chronic disease management.

• Improving the client care experience.

• Ensuring health system accountability and sustainability.

This review also recognizes the financial context of rehabilitative care reform. Health System Funding

Reform is challenging large and medium-sized hospitals and the Community Care Access Centres

(CCAC) to review who accesses service and how to best provide care. In the North West LHIN, the three

hospitals affected by the Health-Based Allocation Model are Thunder Bay Regional Health Sciences

Centre (TBRHSC), SJCG in Thunder Bay, and Lake of the Woods Hospital in Kenora. The rest of the

hospitals in the North West LHIN are considered small hospitals and receive global funding. Health

System Funding Reform has an effect on all hospitals, but significantly impacts how the three hospitals

operate inpatient and outpatient services and will be examined in more detail in the findings section of

this report.

Rehabilitative Care Alliance (RCA) Background

The RCA is a provincial, task-oriented, collaborative group created to effect positive changes in

rehabilitative care across Ontario. It was created in 2013 by Ontario’s 14 LHINs in response to the need

to develop standardization across Ontario’s rehabilitative care system. The RCA utilizes several task and

advisory groups, with broad stakeholder engagement, to develop tools and definitions to help service

providers improve system integration and ensure the quality and sustainability of rehabilitative care

services.

Within the first mandate (April 2013-April 2015), the following key priorities were addressed:

• Definitions – the development of standardized definitions and standards of practice for all levels

of rehabilitative care (Appendix A and B).

• Capacity Planning & System Evaluation – the development of a standard rehabilitative care

capacity-planning and evaluation toolkit (C).

22

• Frail Senior/Medically Complex – the development of an approach for frail senior and medically

complex populations to support the Assess and Restore framework.

• Outpatient/Ambulatory – the development of a standardized minimum data set for outpatient/

ambulatory rehabilitation to inform evaluation and planning at all levels of care.

• Re-classification of Rehabilitation/CCC beds – development of a standardized provincial process

to evaluate the need to re-classify CCC to inpatient rehabilitation beds (Appendix D).

These five mandates provide the foundation of this rehabilitative care review, with the utilization of the

RCA capacity-planning toolkit as a guiding document to create the report. Capacity planning exercises

are taking place throughout Ontario in order to align with the RCA work and the need to standardize

rehabilitative care across the province. The RCA has been extended for a second mandate (April 2015-

April 2017) to support the LHINs in the implementation of the above standardized tools, processes, and

frameworks and develop tools and frameworks for implementation of Quality Based Procedures (QBPs)

for Hip Fracture and Total Joint Replacement. This report also considered other local, provincial and

federal initiatives as outlined in the Project Charter (Appendix E).

Overall, this capacity planning exercise aligns with the strategic initiative of building an integrated

healthcare system. The anticipated outcomes of an integrated model for rehabilitative care will improve

access to care as close to home as possible for all clients, while promoting best care practices. Significant

strategies to achieve this include defining which basket of rehabilitation services will be available at the

Local Health Hub (LHH), Integrated District Network (IDN) and Regional levels; the use of technology

for system integration and service provider networking; and referral management.

Methodology

The North West LHIN Rehabilitative Care Capacity Plan and integrated service delivery model were

created through the analysis and synthesis of qualitative and quantitative information including:

• Community engagement across the North West LHIN.

• Existing reports of the North West LHIN and Ministry of Health and Long-Term Care.

• Provincial initiatives led by the provincial RCA and Greater Toronto Area Rehabilitation Network.

• A literature review focused on integrated models of care and rural and remote communities.

• Consultations with neighbouring LHINs.

• Quantitative data from multiple sources (Appendix F).

A review of the current state of inpatient, outpatient and community-based rehabilitative service, both

CCC and Rehabilitation, was completed in order to identify current practices within the region. A desired

future state model of care was developed based on current best practices, aligning with identified

provincial standards of care, and stakeholder engagement. Subsequently, current system strengths and

23

gaps were identified within the region in order to leverage regional strengths and develop a

comprehensive regional care model.

The RCA capacity-planning framework (Appendix C) formed the foundation of this review using the

definition of restorative potential as outlined by the RCA: “there is reason to believe the client’s condition

is likely to undergo functional improvement and benefit from rehabilitative care”. This framework guided

the evaluation of bedded levels of rehabilitative care, community/ambulatory care, and bedded, long stays

services and identified limitations of rehabilitative care in NWO across the continuum of rehabilitative

care to inform the development of an integrated model of care. Within this process both the siting

(location) and sizing of rehabilitative-bedded levels of care were reviewed in order to inform where

inpatient services should be located. The opportunity to use technology and mobile service delivery was

also examined within the model of rehabilitative care.

Outside the scope of this review are clients seen within dedicated acute care, hospice/palliative care,

mental health, or long-term care beds and pediatric clients. Acute care is discussed in relation to the

demand and provision of inpatient rehabilitative care. The review does include clients in acute care who

could be served in “post-acute” care or were alternative level of care within this resource. This capacity

planning exercise does not provide a detailed analysis of specific medical conditions, and/or condition

prevalence. Rehabilitative care in other parts of the province was not examined except to explore

comparative data or approaches in regions similar to NWO.

The local review process had oversight by a project-specific governance structure. This included North

West LHIN and SJCG executive sponsorship and the use of the SJCG Physical Rehabilitation Advisory

Committee (PRAC) to vet the process and recommendations. The PRAC is an existing quarterly advisory

committee with the purpose of providing advice regarding the rehabilitation programs and services at St.

Joseph’s Hospital (SJH). Project-specific terms of reference were developed and the membership of the

advisory committee was augmented to ensure cross-continuum regional representation. Ex-officio

members included SJCG administrative staff and LHIN representation (Appendix G). A data-analysis

working group provided support to the PRAC to review and confirm accuracy of data developed to

inform the rehabilitative review process. The working group included representation from regions east

and west of Thunder Bay, the North West LHIN, acute and rehabilitative cares organizations, and the

North West Health Alliance.

Literature Search

A literature review was conducted on ‘integrated models for rehabilitative care’ and ‘rehabilitation in

rural and remote areas’ and ‘rehabilitation and indigenous populations’. Relevant evidence-based models

of care such as the integrated models of care, the “Hub and Spoke” model of care, and the primary care

approach were identified along with a model for community capacity-building approach. Components of

these models will be incorporated into the regional care model for the North West LHIN. Elements of the

literature review will serve as evidence throughout this plan.

24

Quantitative Data

A detailed analysis of available quantitative data was conducted in order to inform decision making and

illustrate demand for varying types of rehabilitative care across the North West LHIN. Data collection and

analysis for inpatient care used provincial databases for CCC and designated rehabilitation beds and was

completed by Preyra Solutions consulting firm (contracted through the North West LHIN) and the SJCG

Planning and Performance team.

Community Engagement

Extensive community engagement was conducted with key stakeholders including frontline providers,

leadership teams, clients and families. (Appendix H) Input was obtained, directly through individual and

group discussion and indirectly through members of the advisory committee.

The first phase of community engagement took place in the summer of 2015 and aimed to engage

regional administrators throughout the continuum of care, professional advisory committees, Aboriginal

agency stakeholders, and key informants. The primary purpose of these engagement sessions was to

provide an opportunity for discussion and input on the current state of access to rehabilitative services in

the North West LHIN and gaps to be addressed in an ideal future state.

The second phase of community engagement occurred between November 2015 and December 2015. A

mapping exercise, using the RCA definitions framework of bedded and community rehabilitation,

determined alignment with the RCA standardized definition frameworks for inpatient and outpatient care

within all publicly-funded healthcare organizations in the North West LHIN (Appendix I and J). These

results helped to inform the capacity-planning process.

25

The final phase of community engagement was carried out during the fall of 2016. Videos were prepared

and pre-circulated one week prior to site visits to rehabilitation care providers and managers at the

regional hospitals throughout the North West LHIN. Video content included: the proposed integrated

model of care and preliminary recommendations, the RCA levels of care definitions for both inpatient and

outpatient including fictitious case studies, the impending care streams changes at SJH to align with the

RCA rehabilitative care definitions, and information on hip fracture, primary joint replacement and stroke

QBPs. Site visits to rehabilitative care providers, clients and families at all regional hospitals within the

North West LHIN were conducted to inform the current state, verify the recommendations and secure

feedback regarding the integration of rehabilitative care. Identified system strengths and gaps are

embedded throughout the Current State section of the report and details can be found in Appendix K.

Further Aboriginal stakeholder engagement was completed to clarify identified gaps for this population

and to seek feedback on the recommendations and implementation.

Limitations

Throughout the rehabilitative care capacity-planning exercise for NWO, limitations became apparent. The

primary limitation encountered was the quality of available data. Through the capacity-planning exercise,

it was determined organizations do not report data consistently, particularly within designated CCC beds.

Data were also limited to the use of rehabilitative care services within the North West LHIN for both

residents and non-residents of the North West LHIN but did not capture the use of rehabilitative care

services outside the North West LHIN for residents of the North West LHIN. Further information is

required on the use of rehabilitative care services in Manitoba for residents of the North West LHIN. With

respect to data analysis, the capacity-planning exercise was also limited by the applicability of forecasted

data. Data projections are based on provincial normative values and information reported through the

Continuing Care Reporting System (CCRS) for designated CCC beds and National Rehabilitation

Reporting System (NRS) for designated rehabilitation beds. Since most regional hospitals do not report in

the CCRS system, clients receiving rehabilitative care are not represented in the data.

26

Current State Analysis

Demographics, Population Characteristics, Health Status and Behavioural Factors

North West LHIN Context for Planning

The North West LHIN has the smallest population of all Ontario LHINs, with approximately 235, 900

residents. It also serves the largest geographic area of all Ontario LHINs, covering 47% of the province’s

land mass. According to the Integrated Health Service Plan 2016-2019 Common Environmental Scan,

46% of the residents in the North West LHIN live in Thunder Bay, the only large urban population centre

in the region, while 34% of the population lives in rural areas with more than two-thirds of communities

only accessible seasonally, or by air. Among this population, seniors (aged 65+) account for 17% of the

population. The North West LHIN is home to the greatest proportion of people who identify as

Aboriginal provincially; of the total population in the North West LHIN, 21.5% self-report as Aboriginal.

Between 2010 and 2015, the population of North West LHIN has declined by 0.5% in comparison to the

provincial population, which has grown by 5.1%. It is anticipated over the next five to ten years, the

population of the North West LHIN will remain relatively stable, while the overall provincial population

will continue to increase. However, in comparison to the rest of the province, the North West LHIN’s

proportion of seniors is projected to have higher growth. Over the next 20 years, in the North West LHIN,

the proportion of those aged 65 and over is projected to increase from the current 15-16% to 27-28%.

Provincially, the proportion is expected to increase from the current 14-15% to 22-23%. As the

population ages, the demand for high quality rehabilitative care will increase.

To guide the planning and delivery of healthcare services, while acknowledging the unique needs

across the region, the North West LHIN has been divided into five DNs, as shown in figure 2.

27

Figure 2. North West LHIN Integrated District Networks Map

Many of the IDNs are experiencing an overall decline in total population and an increase in the number of

people aged 65 and over. The following table and Appendix L illustrate these differences in population

size, age, language, and Aboriginal identity and the need to consider the unique characteristics of each

IDN when planning for the regional delivery of rehabilitative care.

28

Table 1. 2011 Census Population Characteristics

IDN Total Population % Age 65+ % Aboriginal Identity % Francophone

Northern 21 815 5.5 81.3 0.5

Kenora 43 130 15.6 25.5 2.9

Rainy River 20 370 17.2 22.3 1.8

City of Thunder Bay 127 975 17.1 9.9 2.7

District of Thunder Bay 17 830 13.9 32.4 13.0

North West LHIN 231 120 15.5 21.5 3.4

IDN Minimum 17 830 5.5 9.9 0.5

IDN Maximum 127 975 17.2 81.3 13.0

Sources: 1 . Sta t i s t i cs Canada. 2011 Census. 2 . Sta t is t i cs Canada. 2011 Nat iona l Household Survey. The non -response

ra te for the Abor ig ina l ident i ty quest ion in the NHS was approximate ly 30% for the North West LHIN res idents wi th

s ign i f icant var ia t ion between communi t ies .

In the Northern IDN, for example, there is a smaller proportion of seniors and a large Aboriginal

population (81.3%) spread out across a number of small, remote communities. While the overall

population of the North West LHIN is decreasing slightly, within the Northern IDN the growth of the

younger population is outpacing that of the older population (40.6% vs. 5.5%). This is significant when

planning for future rehabilitative services as this younger population will likely present different

rehabilitative care needs, for potentially an increased frequency of traumatic injury and early onset

chronic diseases. In addition, specific cultural and geographical needs must be taken into consideration

while planning for rehabilitative care in the Northern IDN. Alternatively, the City of Thunder Bay IDN

has a higher number of seniors living in an urban setting, within close proximity to a range of healthcare

services. It is important to consider the unique needs of each community of the North West LHIN in the

development of a regional model of rehabilitative care in order to meet the local healthcare needs of the

population, while leveraging the existing strengths of each IDN.

North West LHIN Health Status and Behavioural Factors

In addition to a widely dispersed geography, the health status and behavioral factors observed in the

North West LHIN lead to increased prevalence of rehabilitative care needs and subsequently a significant

demand on the healthcare system. Compared to the rest of Ontario, the North West LHIN is below

average in relation to:

• Life Expectancy (78.5 years vs. 81.5 years)

• Self-Perceived Health as Very Good or Excellent (58.8% vs. 60.0%)

• Avoidable Death Rate (258 vs. 171 deaths/100,000)

29

• Percentage of the population with a regular doctor (82.7% vs. 91.2%)

According to the North West LHIN Integrated Health Services Plan, the greatest post-acute and

rehabilitation-related health limitations in the region, as compared to the rest of the province, include:

• Greater number of residents with multiple chronic conditions (20%),

• Higher use of acute care for the management of chronic conditions (26%),

• Higher hospitalization rates for Diabetes (228.5 vs. 99.3 per 100 000), Chronic Obstructive

Pulmonary Disease (COPD) (371.1 vs. 182.4 per 100 000) and Congestive Heart Failure (CHF) (278.4 vs.183.8 per 100 000),

• Higher level of frailty for those aged 75+ (by 45-55%)

• Higher smoking rates (23.6% vs. 18.0%)

• Higher alcohol consumption rates (25.2% vs. 17.2%)

• Higher obesity rates (65.2 %vs. 53.5%)

• Third lowest labour force participation rate in the province

• Largest proportion of residents without a certificate/degree or diploma and a lower proportion

without completed post-secondary education, which contributes to lower literacy levels in the

population.

The health status of Aboriginal people in Canada is poorer than non-Aboriginal people on most

measureable health indicators. Within the North West LHIN, Aboriginal adults are more than twice as

likely as the non-Aboriginal population to die of preventable causes. This represents a decrease in life

expectancy of on average five to seven years as compared to non-Aboriginal people. Remote populations,

large geographic areas, language and cultural barriers, low literacy rates, and inter-generational historical

traumas all impact the challenges in timely access to rehabilitation services for this population.

Factors Affecting Health Status and Access

The large geography and relatively small, dispersed population of the North West LHIN represents one of

the most significant challenges in providing rehabilitative care. These factors create challenges in terms of

service delivery, access and travel to care, recruiting and retaining healthcare professionals and support

workers, and healthcare costs per capita. Further impeding the delivery of rehabilitative care in the North

West LHIN is the lack of road access to one third of communities.

Utilizing population-based growth research, projections indicate an increase in demand for rehabilitation

due to population characteristics and an aging population. However, the overall population of the North

West LHIN is decreasing relative to the rest of the province. Since funding formulas are population- and

volume-based, this presents additional challenges to rehabilitative care service delivery. As such, it is

essential to identify how the North West LHIN differs from other provincial districts. Specifically, due to

the cultural and societal differences described above, the population in the North West demonstrates a

higher degree of frailty and the typical medical concerns related with aging frequently occur at a younger

age, making it difficult to draw comparisons to provincial norms. It is anticipated services associated with

30

the frail elderly, including rehabilitative care, will represent the area highest need due to the sharp rise in

the number of seniors.

Inpatient Rehabilitation

This section of the review includes a detailed evaluation of the current and expected rehabilitative care

needs across the region, including the utilization of Rehabilitation, Convalescent Care and Complex

Continuing Care beds across the region. This includes a comparison of the number of clients reported in

each facility, the number of clients from each community who are receiving care, and identification of

potential limitations in the accuracy of reported number including the impact of Alternative Level of Care

(ALC).

According to the North West LHIN population health profiles, Table 2 outlines the breakdown of

inpatient beds across NWO for all bed types.

Table 2. Summary of current bed allotment in NWO

Hospital Acute* Inpatient

Rehabilitation CCC CCB Total Beds

Thunder Bay Regional Health Sciences Centre 375 375

St. Joseph’s Care Group 50 174 224

Lakehead Manor 9 9

City of Thunder Bay IDN Total 375 50 174 9 608

Lake of the Woods District Hospital 71 71

Dryden Regional Hospital 31 10 41

Red Lake Margaret Cochenour Memorial Hospital 14 4 18

Kenora IDN Total 116 14 130

Atikokan General Hospital 11 8 19

Riverside Health Care Facilities Inc. –

Emo Health Centre 3 4 7

Riverside Health Care Facilities Inc. –

La Verendrye Hospital (Fort Frances) 40 20 60

Riverside Health Care Facilities Inc. – Rainy River Health Centre

3 3

Rainy River IDN Total 57 28 89

Geraldton District Hospital 23 7 30

Manitouwadge General Hospital 9 9

Wilson Memorial General Hospital 9 12 21

Nipigon District Memorial Hospital 15 7 22

The McCausland Hospital 10 13 23

Thunder Bay District IDN Total 66 39 105

Sioux Lookout Meno Ya Win Health Centre 41 8 41

Northern IDN Total 41 8 41

TOTAL 655 50 263 13 981

Includes Medica l /Surg ica l Beds, Obste tr i ca l , Menta l Hea l th , In tens ive Care Uni ts and Acute ped ia tr i cs beds in reg iona l

hosp i ta ls ; Does not include Obste tr i ca l Bassinets

The Auditor General Report identifies inpatient rehabilitation to include both regular (frequent sessions

for a short term) and restorative (slower-paced and over a longer term) with regular rehabilitation being

delivered in a designated rehabilitation bed and restorative rehabilitation being delivered in a CCC

31

designated bed. Designated rehabilitation beds deliver programs that are short-term with frequent

rehabilitation sessions. They are also known as high-tolerance, short-duration rehabilitation. Nationally,

data for these beds are reported using the National Rehabilitation Reporting System (NRS) at either a

general rehabilitation or special (more extensive) rehabilitation level.

The MOHLTC defines CCC as “[the provision of] continuing, medically complex and specialized

services to both young and old, sometimes over extended periods of time. CCC is provided in hospitals

for people who have long-term illnesses or disabilities typically requiring skilled, technology-based care

not available at home or in long-term care facilities”. Within the North West LHIN, the expectation is all

designated CCC beds will be utilized for clients who fall within this definition. Currently, the definition

utilized for CCC varies between facilities provincially.

As a result, the RCA has recently standardized inpatient rehabilitative care definitions. It has been

provincially mandated these definitions be adopted by April 2017, supporting the need to accept a

common definition across the region for the care provided. According to the RCA, there are four

definitions of rehabilitative care, any of which may apply to clients admitted to a CCC or rehabilitation

unit. These definitions outline the client characteristics; medical, nursing and allied health resources; and

reporting tools for each level of client needs. Implementation of bedded levels of care (standardized

inpatient rehabilitative care definitions) must ensure these common definitions are utilized by all facilities

within the region.

The categories of bedded-levels of care expected in Rehabilitation or CCC designated beds include:

Rehabilitation, Activation/Restoration, Short-term Complex Medical Management, and Long-term

Complex Medical Management. Key characteristics of each of the categories are described in Table 3 and

are detailed in Appendix A.

32

Table 3. RCA Bedded-Levels of Rehabilitative Care Definitions

Rehabilitation Activation/

Restoration

Short Term

Complex Medical

Management

Long Term

Complex Medical

Management

Functional Goal Progression Progression Stabilization &

Progression

Maintenance

Target Population

Medically stable,

able to participate

in comprehensive

rehabilitation

program

Medically stable,

cognitively &

physically able to

participate in

restorative

activities

Medically complex

with LT illnesses,

requiring ongoing

medical/ nursing

support where this

level of care cannot be

met at home or in

Long-term Care

(LTC)

Medically complex

with LT illnesses,

requiring ongoing

medical/nursing

support where this

level of care cannot

be met at home or in

LTC

Average LOS ≤90 days (56-72 days) ≤ 90

days

Up to 90 days Will remain at this

level

Discharge Indicator

Rehab goals met,

access to

MD/Nursing care

no longer required

Rehab goals met,

access to

MD/Nursing care

no longer required

Medical/functional

recovery to allow

patient to safely

transition to next level

of rehab care of

alternate environment

Patient is designated

to be more or less a

permanent resident in

the hospital & will

remain until

medical/functional

status changes

Medical Care

Daily physician

access

Weekly physician

access/follow-up

Access to scheduled

physician care/daily

medical oversight

Access to weekly

physician follow-up/

oversight- up to 8

monitoring

visits/month

Nursing Care

Up to 3 hrs/day

Some may go up

to 4 hrs

≤ 2 hrs/day >3hrs/day >3hrs/day

33

Rehabilitation Activation/

Restoration

Short Term

Complex Medical

Management

Long Term

Complex Medical

Management

Therapy Care

Direct care by

regulated health

professionals and

as assigned to

non-regulated

professionals

Consulted by

regulated health

professionals,

delivered by non-

regulated

professional as

assigned

Regulated health

professionals to

maintain/maximize

cognitive, physical,

emotional, functional

abilities. Supported by

non-regulated

professionals as

assigned

Regulated health

professionals to

maintain/maximize

cognitive, physical,

emotional, functional

abilities. Supported

by non-regulated

professionals as

assigned

Therapy Intensity

15-30 min of

therapy 3X/day up

to 3 hrs/day based

on patient

tolerance

Group or 1:1

setting throughout

day. 30min or up

to 2 hrs/day, 5-7

days/week

Up to 1 hr as tolerated

by the patient

Regulated health

professionals

available to maintain

and optimize

functional activities

Engagement with rehabilitation healthcare providers and the results of the RCA mapping tool identified

consistent use of non-traditional bed types to provide rehabilitative care. While it is the mandate of the

RCA to implement the definitions framework across the province, the low number of admissions within

the small hospitals in North West LHIN present challenges to assigning a specific bedded level of care.

Each admission within the small and medium hospitals is unique and ultimately changes the overall

hospital demographics. In addition, small hospitals struggle with the availability of long-term care (LTC)

beds and clients awaiting LTC placement (ALC for LTC) occupy most of the designated CCC beds. As a

result, acute care beds are currently being used to provide the required level of rehabilitative care for each

individual admitted. This practice of using beds flexibly in small, rural hospitals to appropriately meet the

needs of clients benefits clients and supports the flexibility required due to low client volumes. This was

highlighted in the Walker report addressing ALC issues and care for frail seniors, supporting the need to

provide care in a flexible way due to the lack of an alternative setting which could appropriately meet the

needs of the client.

Ongoing consistent, accurate data collection procedures will provide a clear picture of the care needs

across the region and help to determine the most appropriate location for rehabilitation beds in the future.

Dialogue has indicated a need for specific beds allocated as ALC to LTC and an accurate way to estimate

the appropriate CCC bed allocation. The first step is to accurately report the current inpatient therapy

provided to clients in regional hospital settings. Table 4 summarizes the current approximate number of

patient cases and lengths of stay for clients at three of the four rehabilitation levels of care, as defined by

the RCA. The Activation/Restoration level is not included in the summary as this level of rehabilitative

care is ideally provided in designated LTC beds and is reported in the Convalescent Care Bed section of

the report. Full details are provided in Appendix M. Rehabilitation professionals provided these numbers

during onsite engagement sessions at each of the hospitals across the North West LHIN.

34

Table 4. Current Estimated Number of Beds for Rehabilitative Levels of Care in Regional

Hospitals (Sept-Oct 2016)

IDN Facility # of

Beds

Bed

Type # Pts

Avg.

LOS

Est

Avg

Bed

Days/

Mth

Est

Bed

Req

%

Acute

Care

Beds

District of

Thunder

Bay

Geraldton District Hospital 23 Acute 2 1-3

mths 60 2.00 8.7%

Manitouwadge District

Hospital 9 Acute 2

1-4

wks 33 1.10 12.2%

Nipigon District Memorial

Hospital 15 Acute 7

2 wks-

yrs 170.5 5.68 37.9%

McCausland Hospital

(Terrace Bay) 10 Acute 9

3 wks-

yrs 216 7.20 72.0%

Wilson Memorial General

Hospital

(Marathon)

9 Acute 5 3 wks-

yrs 145 4.82 53.6%

Northern Sioux Lookout Meno Ya Win

Health Centre 41 Acute 15

1 wk-

yrs 450 15.00 36.6%

Kenora

Lake of the Woods District

Hospital 71 Acute 13 2d-yrs 278 9.27 13.0%

Dryden Regional Health

Centre 31 Acute 10

2 wks-

yrs 255 8.50 27.4%

Margaret Cochenour

Memorial Hospital (Red

Lake)

14 Acute 4 1 wk-

yrs 88 2.93 20.9%

Rainy

River

Fort Frances LaVerendrye

Hospital 40

Acute 18 2d-yrs 540 18.00 45.0%

Atikokan General Hospital 11 Acute 3 3d-yrs 79 2.63 23.9%

Total 274 78 2,314 77.13 28.1%

#=number;Pts=Pat ients;Avg=average; LOS=Length o f Stay, Req=Required; Est .=est imated; wk=wee ks; d=days; m th=months;

yr=year

35

Inpatient Rehabilitation Beds

The only place to receive extensive, specialized inpatient rehabilitative care in NWO is within a

designated inpatient rehabilitation bed. The corresponding RCA-defined level of rehabilitative care in

these beds is the rehabilitation level. Care is focused on the trajectory of progression and provides a time-

limited, coordinated, interprofessional plan of care “to promote reach and maintain optimal physical,

sensory, intellectual, psychological and social functional levels.” Achievement of client-identified goals

requires frequent or daily reassessment by rehabilitation professionals to create the treatment plan.

Typically, rehabilitation clients require up to three hours of daily nursing care, and rehabilitation 15-30

minutes three times daily up to three hours daily for up to seven days a week. These beds are designed to

support adherence to best practice standards for rehabilitation and are essential in the provision of

specialized inpatient care associated with the delivery of QBPs for stroke, hip fractures and primary joint

replacements. See page 33 for details.

In the North West LHIN, SJH is the only facility with designated inpatient rehabilitation beds.

Rehabilitation inpatient services are located at SJH due to the population and rehabilitative care needs of

the City of Thunder Bay and proximity to the tertiary acute care provider, TBRHSC, which provides

specialized acute care services to many client populations, including those on QBP pathways, those with

spinal cord injuries (both traumatic and non-traumatic), acquired brain injuries, multiple traumas,

amputees, and those who require specialized inpatient or outpatient post-acute care. The

recommendations for designated rehabilitation beds within the QBP framework outline the need for care

by an interdisciplinary team with specialized knowledge of the QBPs and adherence to condition-specific

best practices. In addition, it is recommended clients at the rehabilitation-level of care receive a minimum

of twice daily therapy by the team. Quality-based Procedure care requirements indicate a need for

specialized services within designated rehabilitation beds.

St. Joseph’s Hospital in Thunder Bay has an allocation of 50 rehabilitation beds across two units of care:

a general rehabilitation unit and a special rehabilitation unit. Both programs are designed to provide high

intensity, time-limited, interprofessional, coordinated inpatient rehabilitation care for medically stable

clients. General rehabilitation is specifically designed to provide rehabilitative care for clients with the

primary diagnoses of hip and/or knee replacement (complicated cases), amputation (prosthetic training

stage), hip fractures, spinal cord injury, neurosurgical conditions, and other orthopaedic injuries. Special

rehabilitation provides rehabilitation for client’s who have experienced a stroke and/or acquired brain

injury.

Rehabilitation Bed Utilization

In order determine utilization of rehabilitation beds, an exploration of the fiscal years 2013 to 2015 was

completed. Key elements reviewed included: wait times, percent occupancy, patient days, average length

Recommendation #1: Improve client experience and outcomes through the implementation of

the RCA definitions framework to align rehabilitative care in the North West LHIN within the

provincial framework

36

of stay (LOS), admission rates, and discharge rates. This evaluation identified some differences between

the two rehabilitation units at SJH. General rehabilitation demonstrated a greater client turnover and

lower total occupancy rate until 2015/16, when occupancy in general rehabilitation surpassed special

rehabilitation (Table 5). As indicated in table 5, special rehabilitation exhibited a significantly longer

client LOS, contributing to the high wait time in 2013/14, but as LOS decreased, wait time and ALC for

rehabilitation days at TBRHSC also decreased significantly (see Table 6), and both units have an average

wait time of two days to admission. Wait times will continue to decrease as LOS targets, based on

provincial averages, QBPs, and best practices are implemented at SJH, resulting in shorter LOS and

therefore improved access.

Table 5. SJCG Inpatient Rehabilitation Beds Utilization Data

Service Year Admissions Discharges Expired Patient

Days

Average

Length of

Stay

Percent

Occupancy

Average

Wait

for

Admission

(days)

General

Rehabilitation

2013/14 282 280 0 8196 28.7 89.82 2.4

2014/15 265 266 0 8567 32.8 93.88 2.0

2015/16 291 295 0 8609 29.7 94.09 2.0

Special

Rehabilitation

2013/14 200 201 2 8842 42.9 96.90 7.0

2014/15 206 206 1 8739 42.8 95.77 3.0

2015/16 222 223 1 8468 38.6 92.55 2.0 Source: Medi tech

37

Table 6. TBRHSC Inpatient ALC Cases by Discharge Disposition 2013/14 and 2015/16

FY 2013/14 FY 2015/16

DISCHARGE DISPOSITION TOTAL

CASES

ALC

Days as

Beds/

Day

% of

Total ALC

Days

TOTAL

CASES

ALC Days

as

Beds/Day

% of

Total

ALC

Days

Discharged to Home/Home Setting with

Support 14,891 11.7 18.80% 15,327 14.1 23.5%

Transferred to Continuing Care - SJCG

SJCG-CCC 706 18.8 30.20% 789 13.7 22.9%

SJCG-Special Rehabilitation 152 1.6 2.60% 176 1.8 3.0%

SJCG-General Rehabilitation 217 1.7 2.70% 229 2.0 3.4%

SJCG-Subtotal 1,075 22.1 35.50% 1,194 17.5 29.3%

Transferred to Continuing Care - Other 2,318 28.4 45.7% 2,302 25.0 47.2%

GRAND TOTAL 18,284 62.2 100.00% 18,823 56.6 100.0%

Table 7 presents the rehabilitation bed use (discharge case volumes) by Rehabilitation Patient Group

(RPG), as reported through NRS. During 2015/16, 498 episodes of care (EOC) were served within these

two units with an average LOS of approximately 35 days (Table 8).

Table 7. SJCG Rehabilitation Discharged Case Mix Volume 2011-2016

SJCG Cases

2010-

2011

2011-

2012

2012-

2013

2013-

2014

2014-

2015

2015-

2016

Amputation, Lower Extremity 18 20 17 23 34 15

Amputation, Not Lower Extremity 1 0 1 0 0 0

Fracture of Lower Extremity 68 71 103 95 103 103

Maj Mult Trauma with Brain or

Spinal Cord Injury 1 1 2 3 9 1

Maj Mult Trauma, Oth Mult Trauma

& Maj Mult Frac 5 3 7 6 9 8

Neurological 12 14 12 13 10 15

38

SJCG Cases

2010-

2011

2011-

2012

2012-

2013

2013-

2014

2014-

2015

2015-

2016

Non-Traumatic Brain Injury 8 10 13 9 11 18

Non-Traumatic Spinal Cord Injury 4 4 7 28 30 40

Osteoarthritis 15 11 14 12 3 0

Other Disabilities 1 0 0 1 4 6

Other Orthopedic 11 29 11 15 14 21

Pain 8 3 15 12 4 3

Replacement of Lower Extremity 233 186 58 54 60 75

Rheumatoid Arthritis and Other

Arthritis 35 40 38 32 15 9

Stroke 126 130 138 130 130 161

Traumatic Brain Injury 12 18 19 20 9 20

Traumatic Spinal Cord Injury 2 4 2 4 7 1

Pulmonary 0 1 0 0 0 0

Cardiac 0 0 0 0 0 2

Total 560 545 457 457 452 498

Table 8. SJCG Rehabilitation Average Case Mix LOS days/Case 2011-2016

Average Case Mix LOS days / Case

2010-

2011

2011-

2012

2012-

2013

2013-

2014

2014-

2015

2015-

2016 Amputation, Lower Extremity 43.3 60.1 69.2 50.0 34.6 35.7 Amputation, Not Lower Extremity 99.0 15.0 Fracture of Lower Extremity 36.2 25.5 37.0 37.5 37.7 30.5 Maj Mult Trauma with Brain or Spinal Cord Injury 33.0 149.0 13.5 57.0 57.4 62.0 Maj Mult Trauma, Oth Mult Trauma & Maj Mult Fracture 36.6 52.3 30.0 30.0 58.9 60.6 Neurological 80.0 48.2 96.3 40.0 73.7 65.5 Non-Traumatic Brain Injury 84.9 72.9 56.2 33.1 64.5 44.3 Non-Traumatic Spinal Cord Injury 58.3 50.8 44.9 51.3 63.5 34.7 Osteoarthritis 14.2 13.3 11.9 11.8 12.3 Other Disabilities 65.0 11.0 36.0 20.5 Other Orthopedic 29.8 23.4 39.1 34.9 37.6 41.7 Pain 13.0 12.7 11.1 11.2 11.8 15.0

39

Replacement of Lower Extremity 15.4 13.3 23.6 26.2 23.5 24.2 Rheumatoid Arthritis & Other Arthritis 14.2 13.3 11.9 11.4 11.2 11.0 Stroke 43.0 40.8 45.6 39.4 36.4 38.5 Traumatic Brain Injury 102.3 36.7 73.8 62.8 58.0 44.1 Traumatic Spinal Cord Injury 44.0 185.5 66.5 128.3 78.4 56.0 Pulmonary 27.0 Cardiac 27.5

Average 30.3 28.5 39.1 36.7 38.9 35.2 Source: CIHI NRS

Between 2010/11 and 2015/16, the number of clients admitted to rehabilitation beds has decreased from

560 to 498. During the same time frame, total LOS increased from an average of 30.3 days to 35.2 days, a

16% increase. The decrease in volume and increase in LOS is primarily due the introduction of the

primary joint replacement QBP in 2012. The QBP prompted a change in referral pattern from acute care

directly to outpatient rehabilitation, without an inpatient rehabilitation admission resulting in a significant

decrease in the number of clients admitted for inpatient care following a replacement of lower extremity;

specifically hip and knee replacement surgery. Consequently, the type of clients admitted to post-acute

rehabilitative care changed to include more complicated clients such as those with bilateral replacement

of lower extremity, multi-trauma, and hip fractures with a corresponding longer length of stay.

Additionally, in 2014/15 the number of inpatient rehabilitation clients identified with a primary diagnosis

of arthritis decreased significantly as a result of changes in SJH admission practices for this population. In

order to best utilize scarce and expensive inpatient rehabilitation resources and improve flow to inpatient

rehabilitation, the North West LHIN funded community accommodation to support regional clients in

accessing the specialized rheumatic disease outpatient program at SJH. Currently, community

accommodation is provided whenever possible; however, on occasion, Non-Insured Health Benefits

(NIHB) medical transportation policy for Aboriginal clients stipulates the service must be provided at an

inpatient level. Without medical transportation funding, clients cannot access the service in Thunder Bay

even if accommodation is provided. The discussion continues with NIHB regarding the need to support

clients without an inpatient stay.

Furthermore, between 2011/12 and 2013/14 there was a corresponding increase in clients admitted for

rehabilitation associated with a Fracture of Lower Extremity (primarily hip fracture) and non-traumatic

spinal cord injury, with an increase in LOS. In 2013, the number of non-traumatic spinal cord injury

admissions increased, due to a targeted service increase with corresponding resources, to address the

previous service gap in the system for this population. As evident in Tables 5 and 7, the number of

admissions as well as a significant number of patient days has increased. Recent work on benchmarking

and target LOS has been implemented to improve inpatient lengths of stay for both traumatic and non-

traumatic spinal cord injuries, as well as clients experiencing a stroke. Since 2015, improvement

initiatives were implemented at SJH to reduce hip fracture length of stay by seven days to move towards

provincial average.

Overall, the average case mix LOS has decreased by 3.7 days per case since 2014-15 (Table 8). Length of

stay has significantly decreased for higher volume cases such as fracture of lower extremity (7.2 days)

and non-traumatic spinal cord injury (28.8 days). However, current LOS performance is above provincial

average for many RPGs (Table 9). Table 9 shows both the North West and the North East LHIN have

40

significantly longer average lengths of stay compared to the rest of Ontario. It is that hypothesized rural

and remote discharge destinations and limited access to outpatient services may have a role in the

increased LOS for these LHINs. To increase access to inpatient rehabilitation and reduce cost per case,

SJH is continuing to focus on reducing LOS. A LOS target has been set for all RPG-based on provincial

average or best practice and QBPs, when available. Individual case reviews occur at SJH when actual

LOS is expected to exceed the target, in order to identify and remove barriers to discharge. As noted in

Table 10, these strategies have resulted in improved FIM change score (22.1 in 2013 to 24.2 in 2015) and

the North West LHIN change scores are now higher than ten other LHINs, and slightly above the

provincial average.

Table 9. Ontario Case Mix Volumes and Average LOS days by LHIN, 2015-2016

Facility Region

Case Mix

Clients

(COUNT)

Case Mix

Avg LOS

Erie St. Clair 1,958 22

South West 2,010 28

Waterloo Wellington 1,092 24

Hamilton Niagara Haldimand Brant 2,811 27

Central West 1,156 26

Mississauga Halton 2,602 24

Toronto Central 7,032 28

Central 3,899 23

Central East 2,961 25

South East 943 28

Champlain 3,628 23

North Simcoe Muskoka 394 25

North East 915 35

North West 498 35

Source: CIHI NRS

41

Table 10. Inpatient Rehabilitation Average Admit, Discharge, and FIM Change Scores /LHIN

FY 2013 FY 2014 FY 2015

LHIN

Avg.

Admit

FIM

Avg.

D/C

FIM

Avg.

FIM

Change

Avg.

Admit

FIM

Avg.

D/C

FIM

Avg.

FIM

Change

Avg.

Admit

FIM

Avg.

D/C

FIM

Avg.

FIM

Change

Central 73.2 91.8 18.3 71.1 91.0 19.8 73.1 92.8 19.5

Central East 73.8 97.5 23.0 70.2 94.0 23.4 70.7 93.6 22.9

Central West 80.5 100.8 19.0 76.0 100.3 22.1 75.1 98.2 21.7

Champlain 80.9 101.1 19.9 81.0 99.2 17.7 78.6 98.5 19.5

Erie St. Clair 77.6 97.3 19.1 72.4 92.9 20.1 71.5 92.7 20.7

Hamilton Niagara Hald.

Brant 79.7 100.8 20.5 78.4 99.8 21.1 79.4 100.7 21.0

Mississauga Halton 68.9 91.5 22.5 67.7 89.5 21.6 64.4 88.5 24.1

North Simcoe Muskoka 75.6 103.4 26.1 74.7 104.5 29.0 75.1 101.6 25.7

North -East 77.4 98.5 20.8 78.1 97.9 19.5 78.6 99.4 20.3

North - West 80.2 103.2 22.1 75.5 99.1 22.8 75.4 101.2 24.2

South East 74.8 94.4 19.2 74.4 93.6 19.1 74.1 91.8 17.7

South West 77.1 97.9 20.7 75.0 95.0 19.9 75.9 96.5 20.5

Toronto Central 82.4 106.4 23.8 80.0 104.5 24.2 78.2 104.0 25.6

Waterloo Wellington 78.1 100.1 21.8 70.7 96.1 25.6 70.6 96.9 26.0

PROVINCE-

ONTARIO 78.3 100.2 21.9 76.1 98.3 21.9 75.2 98.0 22.6

Quality Based Procedures (QBP) and Best Practices

One of the key factors in the provision of care in rehabilitation is the recent introduction of QBPs for

several of the most common medical conditions requiring care. The goal of QBPs is to promote

innovation in healthcare delivery. In June 2010, the Excellent Care for All Act was legislated, formally

mandating improvements in quality and value of client experiences within the healthcare system.

Specifically, the Act directs the provision of the right evidence-informed healthcare, at the right time, and

42

in the right place, throughout the continuum of care: acute to post-acute to in-home, and

outpatient/community services.

Quality-based procedures play a key role in linking high quality care delivery and fiscal responsibility

within the Act. This evidence-informed pricing strategy encourages providers to adopt best practice

standards, modify clinical processes to improve client outcomes, and develop innovative care delivery

models to enhance the client care experience. Through the full implementation of QBPs, improvements in

discharge planning, elimination of unnecessary assessments, and closer attention to post-operative

complications will be realized.

In the development of any future state of rehabilitative care, it is important to consider the role of existing

and proposed QBP’s. It is recommended that enhanced post-acute rehabilitative care be adhered to as

identified in the QBP handbooks. These documents were developed to help support the implementation of

QBPs in clinical practice in consultation from the MOHLTC, Health Quality Ontario, and diagnosis-

specific expert panels. The RCA is currently reviewing the Total Joint Replacement and Hip Fracture

Handbooks to ensure outpatient recommendations are based on best practices for optimal outcomes and

attempt to measure the impact of implementation on client outcomes. An advantage of QBP

implementation is the development of client-centred pathways, reflecting the full continuum of care a

client needs from acute inpatient to post-acute inpatient to outpatient/community services.

Quality-based procedures are developed for clinically-related diagnoses or treatments. Among the

conditions with developed QBPs requiring rehabilitative care are: Primary Joint (Hip and Knee)

Replacement (implemented), Hip Fracture (not yet implemented), Stroke (not yet fully implemented), and

to a lesser extent Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF).

Please refer to Table 7 for rehabilitation trending for these populations.

Stroke

Clients with a stroke are a large client population in need of rehabilitation services. From 2010/11 to

2015/16, the number of people with a stroke, as a percentage of all rehabilitation clients, increased from

126 cases (22.5%) to 161 cases (32.3%). Of all clients with a stroke, 65-75% are seniors (65+ years) but

the number of clients within this age range has decreased over the past five years. This may indicate an

increased prevalence of people with a stroke who are less than 65 years. Approximately 50% of all

rehabilitation clients with a stroke were female, and 55% were seniors.

Clients with a stroke with an alphaFIM (Functional Independence Measure) score of 40-80 (minimum

score of 18 indicating lowest function to maximum score 126 indicating highest function) are admitted to

the Special Rehabilitation Unit at SJH in accordance with the stroke pathway protocol (currently being

updated). The alphaFIM is a standardized assessment to determine the care needs for clients following

stroke and other medical events. Clients are considered for admission to a rehabilitation bed if they

demonstrate restorative potential and the ability to tolerate a high intensity level of rehabilitation, up to

three hours daily.

43

Hip Fracture

Hip fracture rehabilitation cases have shown substantial growth in the past six years, from 57 cases in

2010/2011 (10%) to 89 cases in 2015/16 (18%). The majority of these clients were seniors (93%-96%)

and 70% were female. Clients with hip fractures are seen on the General Rehabilitation Unit if they are

from the City of Thunder Bay or if their care needs are unable to be met in their IDN or LHH. Most

components of the hip fracture QBP are initiated in acute care at Thunder Bay Regional Health Sciences

Centre (ie. Orthopaedic consult, bone density testing, geriatric assessment) and their rehabilitative care

needs can usually be met locally. As such, following surgery and stabilization at the Thunder Bay

Regional Health Sciences Centre, clients are repatriated to their home hospital for rehabilitation. This was

confirmed during community engagement sessions with both healthcare providers and clients and

families. On occasion, there are reported difficulties in nursing rehabilitative care knowledge and skills

and health human resources in the smaller LHHs, which may necessitate admission to the regional

rehabilitation unit. See Appendix N for the current implemented hip fracture care pathway for the North

West LHIN.

Joint Replacement

The number of joint replacement (unilateral hip and unilateral knee) rehabilitation cases decreased

considerably between the years 2010/11 and 2015/16, as a result of two potential causes:

3. A change in practice and referral pattern from acute care.

4. The increased availability of rehabilitation service delivery in the community.

44

In 2010/2011, joint replacement rehabilitation comprised 191 (42%) of all rehabilitation cases. This

number decreased to 47 (13%) by 2015/16. The majority of cases were seniors, ranging from 72%-87%

over the past six years. Female clients represented 70% of all the cases in both senior and non-senior

cases in 2010/2011 to 2011/2012. By 2014/2015, the female and male ratios became 55% and 45%

respectively. Those referred to inpatient rehabilitation are more complicated clients, including those with

bilateral replacements.

COPD and CHF

Quality-based procedures have been developed for COPD & CHF, with the primary focus on the acute

episodes of care. Both handbooks refer to pulmonary rehabilitation, however the handbooks do not clearly

indicate if this rehabilitation is to be done in acute care, post-acute care, or as an outpatient service. There

is a reference to a transitional care pathway, which has not been defined or confirmed by the expert panel.

The transitional care pathway for CHF refers to community support partners, avoiding inpatient

rehabilitative care unless associated with a co-morbid condition. Overall for CHF, the majority of

discharges is home with or without services (54.21%), followed by discharged to LTC (12.73%), with the

final significant disposition being death in acute care (9.01%). Transfers to another facility providing

inpatient hospital care (including rehabilitation) account for only 4.3% of discharges. Until these

transitional care pathways are reviewed and clarified, the role of rehabilitative care in the pathway

remains unclear. This being said, there is cooperation by service providers (SJH, TBRHSC and CCAC)

underway to establish a central point of access for pre- and post-pulmonary services (including COPD,

CHF), the co-location of services in the City of Thunder Bay, and a model to support clients regionally

through a network of services.

Throughout the North West LHIN, it is imperative that rehabilitative care is coordinated and reflective of

the QBPs. As part of an integrated rehabilitation model, care pathways need to be created or reviewed to

align with the QBPs from pre-operative care, inpatient, outpatient, and to community care for the entire

North West LHIN region. It is essential that the existing Regional Orthopaedic Program and Regional

Stroke Network are collaborative partners in the development, implementation, and sustainability of an

integrated rehabilitation model.

Alternative Level of Care (ALC) Impact on Rehabilitation and Discharge Disposition

In 2015/16 both rehabilitation units experienced bed days attributed to clients designated ALC. Sixty-two

(62) clients were discharged from rehabilitation with a total accumulation of 826 alternate level of care

days (Table 11). These clients completed active rehabilitation and were waiting for a LTC home, other

housing, and/or services in another sector. It is important to also recognize although some regional clients

have completed their rehabilitation needs at SJH; they require local rehabilitation services, such as a home

visit and community support planning. The current process involves repatriation to their LHH, so clients

are not coded as ALC as they transfer to the “acute care” facility in order to arrange for these services.

This results in the reported ALC numbers being lower than they actually are. While these ALC numbers

remain low, they must be accounted for as they can reduce the unit capacity by up to 16% (4 of 25 beds)

at any given time and ultimately limit access to care. Ideally, there should be no ALC days on the

rehabilitation units.

45

Table 11. 2011/12 to 2015/16 Alternative Level of Care Data- SJCG Rehabilitation

Number of Discharges ALC Days

Discharge

Destination

2011-

12

2012-

13

2013-

14

2014-

15

2015-

16

2011-

12

2012-

13

2013-

14

2014-

15

2015-

16

CCC 30 40 38 33 54 893 1478 796 469 728

Home 5 1 4 12 5 39 56 106 149 105

LTC 5 7 4 3 5 142 190 169 47 103

Supportive Housing 5 5 1 5 2 114 210 22 138 36

Other 5 7 3 3 6 61 161 4 1 36

Total 50 60 50 56 72 1249 2095 1097 804 1008

As discussed, improvement initiatives are currently underway at SJH to reduce LOS and ALC rates to

improve flow. This includes designating CCC beds on both rehabilitation units. Clients more appropriate

for CCC-level services will be able to access this care without having to be physically moved to another

unit. The corresponding number of rehabilitation beds will be created on the SJH Geriatric Assessment

and Rehabilitation Care units. This should help eliminate ALC to CCC, except when beds are not

available.

Regional Rehabilitation Needs

As all North West LHIN rehabilitation beds are currently located in the City of Thunder Bay, it is

important to evaluate the regional utilization of these services. Evaluation of all clients admitted to

designated rehabilitation beds for the years 2013-15 was completed using home postal code search. Table

12 outlines the case mix LOS days during the fiscal years 2013-2015 by client’s home IDN. In 2015/16,

the percentage of days relating to clients from the City of Thunder Bay has declined from 74% to 69%,

with remaining 30% of days related to clients from other North West LHIN IDNs and less than 1% of

days from out of province.

46

Table 12. Regional Designated Rehabilitation Bed Usage by IDN based on NRS Reported Days

Client Home

Community/IDN

Allocated

Rehab

Beds

Actual

Case Mix

LOS

Days

2013/14

Actual

Case Mix

LOS

Days

2014/15

Actual

Case Mix

LOS

Days

2015/16

% of

Case Mix

LOS

Days

2013/14

% of

Case Mix

LOS

Days

2014/15

% of

Case Mix

LOS

Days

2015/16

City of Thunder Bay 50 12581 13064 12048 74.8% 74.2% 68.7%

Kenora 0 1686 1852 2028 10.0% 10.5% 11.6%

Rainy River 0 625 747 656 3.7% 4.2% 3.7%

District of Thunder Bay 0 1694 1658 2506 10.1% 9.4% 14.3%

Northern 0 76 262 184 0.5% 1.5% 1.0%

Other ON LHIN 0 0 33 0 0.0% 0.2% 0.0%

Manitoba 0 91 0 102 0.5% 0.0% 0.6%

Saskatchewan 0 0 0 23 0.0% 0.0% 0.1%

Alberta 0 60 0 0 0.4% 0.0% 0.0%

Total Bed Days 16813 17616 17547 100.0% 100.0% 100.0%

This reflects an increase in the number of regional clients receiving post-acute rehabilitation at SJCG. As

discussed, in order to provide adequate specialized care related to best evidence and relevant QBPs,

rehabilitation units must meet specific interprofessional staffing and therapy intensity as well as access to

the services of a physiatrist. These specialized teams are associated with a critical population mass and

client volume. Regional clients require tertiary care services in the City of Thunder Bay for acute care,

surgical and specialized treatments at TBRHSC, supporting the current configuration of rehabilitation

beds within the North West LHIN.

The path from acute to specialized post-acute inpatient services is ideally seamless. There are occasions

where clients are not ready for active rehabilitation and require further convalescing prior to engaging in

active rehabilitation. If these clients are from a regional community, the individual may return home to

wait in a regional hospital and have to return to Thunder Bay again for active rehabilitation. These

transitions can be difficult for clients and families living in the region and clients may elect not to return

to SJH for specialized rehabilitation. This area requires further investigation and collaboration with

clients, families, and regional facilities to determine the best option for rehabilitative care. In all cases,

communication with regional hospitals and/or the CCAC is essential to ensure they are aware of the

rehabilitative care needs of clients discharged to either a regional hospital setting or home. Clients and

families indicate they prefer care close to home, and in some cases, are unaware of the service gaps in

47

their home community until they experience the services at the tertiary care centre. Currently,

communication between care providers across the region is inconsistent. Providers and clients would

benefit from more formal processes to ensure the necessary communication occurs at time of client

transition.

Table 13, compares 2015/16 bed days with Preyra Solutions 2025 expected demand. There is an increase

of 3,467 days for residents outside the City and District of Thunder Bay.

Table 13. Actual and 2025 Forecasted Rehabilitation Days by IDN

IDN Actual

(2015/16)

Expected

(2025)*

Expected-

Actual

City of Thunder Bay 12048 10594 -1454

Kenora 2028 3595 1567

Rainy River 656 1682 1026

District Thunder Bay 2506 1519 -987

Northern 184 1058 874

Total Bed Days 17422 18448 1026

Total Beds 48 51 3

Total Bed at 90% Occupancy 53 56 3

*Source: Preyra So lout ions 2025 Expected Rehabi l i ta t ion Days

As indicated in Table 13, the current estimate of rehabilitative beds required to meet the regional demand

does not support locating beds in each IDN, even in Kenora. However, care pathways to help clients

access appropriate specialized care and return to their home community as soon as feasible, as well as the

development of remote access to specialized services, would support care close to home. As a result of

these requirements and the limited number of clients requiring inpatient rehabilitation within each IDN, it

is recommended rehabilitation beds continue to be located in SJH in the City of Thunder Bay at this time.

The forecasted data also indicates a potential increase of six rehabilitation beds for the North West LHIN.

However, there have been identified data limitations. Considering the need remains close to the

projections and the available current capacity to deliver rehabilitative care outside of Thunder Bay is

limited, it is recommended at this time to maintain the current bed numbers, but closely monitor the

rehabilitation bed demands.

As noted earlier, it is anticipated within NWO the demand for services associated with the frail elderly

population, including rehabilitative care, will increase due to the sharp rise in the number of seniors.

Currently, there is additional funding for some regional hospitals (Lake of the Woods, Dryden Regional,

and Sioux Lookout Meno Ya Win) to provide rehabilitation using the Assess and Restore approach to

care, which serves the frail senior population well. The Assess and Restore philosophy is an approach to

48

care, rather than a bed designation. The MOHLTC defines this philosophy as individualized bundles of

short-term rehabilitative and other restorative care services delivered by integrated teams, which include

regulated health professionals with expertise in geriatrics. Care is directed towards increasing strength,

mobility, and functional ability and is targeted to frail seniors and other persons who have experienced a

recent loss of functional ability following a medical event or decline in health; are at high risk for

imminent hospitalization or admission into a long-stay LTC home bed as a result of functional loss ('high-

risk’); and have the potential to regain functional loss so they are no longer at high risk (‘restorative

potential’). At present, this level of care is happening in CCC or acute care beds throughout NWO, but

meets the criteria for rehabilitation level of care as defined by the RCA bedded-levels of care. The RCA

rehabilitation definition at present indicates the need for data reporting through NRS, which is only done

in designated rehabilitation beds. The RCA is exploring the development of a new category within NRS

to capture these types of clients. A toolkit has been developed by the RCA to help hospitals determine if a

case should be made to their LHIN to convert beds to rehabilitation beds.

Currently, between the designated rehabilitation beds and the level of rehabilitation provided in current

CCC and acute care beds, the majority of rehabilitative care needs is provided within our LHIN.

Strategies are being developed by SJH to decrease hospital LOS, and improve care transitions and the

availability of rehabilitation in regional communities.

Strengths, Gaps, and Recommendations

The quality of care is clearly identified as a strength of the rehabilitation level of care in the North West

LHIN. Clients note staff is always professional, kind, and exceptionally knowledgeable. One family

member noted: “Staff truly cared about my dad and his progress.”

The centralization of designated rehabilitative care beds in Thunder Bay continues to have a negative

impact on clients and families who must remain far from home to receive post-acute services. These

clients already required travel to Thunder Bay to access appropriate specialized acute care at the tertiary

care centre. One client noted: “I wished I could have been home sooner.” Families identified the need for

affordable lodging with kitchenettes or a hostel environment such as Tamarack House for clients with

cancer. Rehabilitative care is always delivered as close to home as possible but in some cases, the most

appropriate location is Thunder Bay to access specialized rehabilitation knowledge, skills, equipment and

intensity. It has been identified during rehabilitation professional engagement sessions that some clients

will elect to receive a different level of care locally versus travelling several hours to a specialized

program. Unfortunately, due to current data limitations, it is difficult to determine the number of clients

affected. These clients will receive the best care possible within their LHHs available resources.

In addition, there were issues noted in communication and collaboration at times of client transitions.

Assumptions were often made regarding the availability of inpatient, outpatient, and/or community

resources when clients moved from Thunder Bay to their LHH. The variability of these services and

availability of rental medical equipment such as walkers and wheelchairs impacted the length of time

clients needed at their LHH before finally returning home. Regional healthcare providers noted a lack of

relevant client information despite a regional electronic medical record.

49

The lack of critical mass and specialized services indicate it is not feasible to reallocate rehabilitative care

beds at this time. It is recommended a system of support be developed for regional rehabilitative clients

who may seek alternate levels of care close to home. Opportunities and recommendations will be

developed within the future state model of care.

Rehabilitation in Convalescent Care – Activation/Restoration (AR)

The RCA has defined an Activation/Restoration (AR) level of care with a progression trajectory like

rehabilitation. However, this level of care differs from rehabilitation with respect to the goal “to promote

activity, increase strength, endurance, independence and ability to manage activities of daily living…with

a focus on restoring function”. The primary focus of rehabilitative care within AR is to provide

opportunities for functional practice, wellness, and self-care activities. This level of care takes place in

Convalescent Care Beds (CCBs). CCB were established to improve patient flow. They are a short stay

program in LTC homes for persons who need time to recover strength, endurance or functioning and are

anticipated to return home. Currently, clients can access a CCB while their weight-bearing restrictions or

healing wounds limit their ability to participate in active rehabilitation or until they have gained strength

and endurance in order to participate in active rehabilitation. Occasionally, clients may also access a CCB

after they have completed active rehabilitation but need additional time to gain strength or endurance to

be able to safely return home. The ultimate objective is to support the return of clients to their previous

living environment.

In order to qualify following an acute episode, clients must be medically stable and cognitively able to

participate in restorative activities designed to enable a return home or progress to a rehabilitative level of

care. Clients are expected to have a discharge location, typically home, and cannot be waiting for

placement in a LTC facility. Clients should not require daily access to a comprehensive interprofessional

rehabilitation team, and should be able to have their needs addressed through exercise and recreational

activities provided primarily by unregulated healthcare providers, such as personal support workers, life

enrichment staff, or rehabilitation assistants, in a group setting. Less than two hours of nursing care per

day is required. Typically, an average length of stay is 56-72 days to a maximum of 90 days.

Recommendation #2: Develop a LHIN-wide strategy to improve client access and

client transitions across the continuum of rehabilitative care

Recommendation #3: Facilitate adherence to best practices for rehabilitative care to

improve client-centred care

Recommendation #4: Enhance utilization of innovative technologies to improve access

to rehabilitative care services closer to home, particularly in remote and underserviced

areas

50

Convalescent Care Bed Utilization

Convalescent care beds in the North West (13 in total) are a small proportion (1.8%) of the total volume

available in Ontario and sited in Fort Frances (4) and Thunder Bay (9). The average LOS ranged from

50.7 days in 2011/12 to 64.3 days in 2014/15. The primary discharge destination is the community at

69.6% for the North West LHIN in 2014/15.

The small number of beds makes occupancy comparisons difficult, as a single bed has a greater impact on

the measure (Table 14).

Table 14. Convalescent Care Program Occupancy rates in the North West LHIN

June 2014 (Q1) Sept 2014 (Q2) Dec 2014 (Q3) March 2015 (Q4) June 2015 (Q1)

Discharge

Destination # Beds

Occ.

Rate # Beds

Occ.

Rate # Beds

Occ.

Rate # Beds

Occ.

Rate # Beds

Occ.

Rate

Lakehead

Manor 9 77.8% 9 100.0% 9 33.3% 9 55.6% 9 100.0%

Rainycrest 4 50.0% 4 100.0% 4 75.0% 4 100.0% 4 75.0%

Ontario 729 88.2% 738 89.0% 755 82.3% 755 86.9% 723 90.7%

Table 2(a) – Source: MOHLTC - CCP Survey, 2016 ; #=number; Occ=Occupancy

Alternative Level of Care (ALC) Impact on CCB

As with other services, CCB are under increasing pressure from ALC clients. The North West LHIN has

the second highest rate of increase in the percentage of ALC days as well as the second highest rate of

increase in ALC days (Table 15).

Table 15. Convalescent Care Program Percentage of ALC Days in Ontario by LHIN 2012/13 to

2014/15

% ALC Days Change in % ALC Days

LHIN 2012/13 2013/14 2014/15 12/13 vs.

13/14 13/14 vs.

14/15 12/13 vs.

14/15

04 HNHB 13.80% 15.16% 18.23% 9.86% 20.25% 32.10%

09 Central East 14.39% 16.14% 16.84% 12.16% 4.34% 17.03%

10 South East 13.58% 13.19% 15.40% -2.87% 16.76% 13.40%

12 North Simcoe Muskoka 23.22% 21.41% 21.02% -7.80% -1.82% -9.47%

13 North East 23.81% 23.67% 23.17% -0.59% -2.11% -2.69%

14 North West 16.52% 17.79% 21.72% 7.69% 22.09% 31.48%

Ontario 14.09% 14.03% 14.35% -0.43% 2.28% 1.85%

Table 2(b) – Source: MOHLTC - CCP Survey, 2016

51

Regional Needs

Table 16 summarizes a snapshot of the number of cases and length of stay for clients at the

Activation/Restoration level of rehabilitative care as defined by the RCA. Rehabilitation professionals

provided these numbers during onsite engagement sessions at each of the hospitals across the North West

LHIN. The staff in Fort Frances indicated an unusually high number of clients requiring AR level of care

for wound healing. It is unknown if this is due to a demographic population need or if this is the result of

the wound expertise developed within this IDN, increasing awareness, and use of inpatient resources to

promote wound care best practices. Further investigation is warranted to determine if these clients could

be managed at a community level of care.

Table 16. Snapshot of the Estimated Number of Beds for Activation/Restoration Level of Care in

Regional Hospitals (Fall 2016)

IDN Facility #

Existing

Beds

Bed

Type

# A/R

Pts

Avg.

LOS

Est. Avg.

A/R Bed

D/ Yr

Est A/R

Beds

Req’d

% of

Acute

Care

Beds

District

of

Thunder

Bay

Geraldton District Hospital 23 Acute 4/yr 4-8 wks 168 0.46 2.0%

Manitouwadge District Hospital 9 Acute 5/yr 3-6 wks 158 0.43 4.8%


Hospital

15 Acute 3-5/yr 6-12 wks 252 0.69 4.6%

McCausland Hospital 10 Acute 1-2 6-8 wks 548 1.50 15.0%


Hospital

9 Acute 6-8/yr 6-8 wks 343 0.94 10.4%

Northern Sioux Lookout Meno Ya Win

Health Centre

41 Acute 6-7 4-8 wks 2,190 6.00 14.6%

Kenora Lake of the Woods District

Hospital

71 Acute 5-6 6-8 wks 1,825 5.00 7.0%

Dryden Regional Health Centre 31 Acute 1-3 6-8 wks 730 2.00 6.4%

Margaret Cochenour Memorial

Hospital

14 Acute 4/yr 4-8 wks 168 0.46 3.3%

Rainy

River

Fort Frances LaVerendrye

Hospital

4 CCB 1 90 days 365 1.00 25.0%

40 Acute 9-12 4-26 wks 3,833 10.50 26.3%

Atikokan General Hospital 11 Acute 1-2/yr 4-8 wks 84 0.23 2.1%

Total 278

10,663 29.21 10.5%

#=number; Est=Est imated; A/R= Act i va t ion /Resto ra t ion ; Avg=Average; LOS=Length o f Stay, wk=weeks; d=days; mth=months;

yr=year;

52


During engagement sessions, healthcare providers indicated some reasons why CCB are not utilized to

their full capacity. Firstly, it was indicated many clients requiring the AR level of rehabilitation are not

able to have their needs met in CCB due to the current criteria of a one-person (not two) assist for all

transfers and mobility; funding limitations for intravenous medications and pumps required for wound

healing; and a limited skill set of LTC nurses for intravenous pumps. As such, in the City of Thunder

Bay, these clients are often admitted to SJG and in Fort Frances to the acute care hospital La Verendrye.

Secondly, clinicians indicated the current process of CCAC managing the CCB admissions is lengthy. For

short lengths of stay of one to two weeks, it is perceived to be easier and more client-centred to have the

client remain where they are until they are able to go home or can access rehabilitation, as CCBs are in a

different physical location. Finally, the criteria indicating the need for a discharge destination of home or

another location (e.g. confirmed rehabilitation bed) also limits availability of this service.

This feedback differs from the recent results of a provincial survey in which barriers to access were

identified as distribution/location of beds, concerns about the ability of the LTC home to meet the

person’s care needs, concerns about the likelihood the client would be ready for discharge within 90 days,

CCAC concerns they were asked to take clients who were inappropriate and would likely end up on the

crisis list, and client/family concerns about leaving hospital and the location or condition of the LTC

home offering CCBs.

Currently, the care needs of these clients are provided primarily in acute care beds throughout the North

West LHIN. Rehabilitation professionals indicated that at hospitals where unregulated health

professionals (PSWs, rehabilitation or physiotherapy assistants) are unavailable, clients receive care

provided by regulated health professionals. This would indicate partial alignment with the rehabilitation

care definitions, but essentially “over treating” the clients, as the appropriate level of service is currently

unavailable. This can only be alleviated by improved utilization of the current CCB capacity, recognizing

the need for additional CCB throughout the NW LHIN, and adding unregulated health professional

resources in facilities offering this level of care.

Inpatient Complex Continuing Care Beds

In contrast to the designated inpatient rehabilitation beds, CCC beds in the North West LHIN are located

throughout the region in regional hospitals (Table 17). With the exception of Manitouwadge General

Hospital, and Lake of the Woods District Hospital who no longer operates CCC beds, all regional

hospitals have allotted CCC beds. The current breakdown of designated CCC beds is as follows:



53

Table 17. Current identified CCC bed allotments in North West LHIN

IDN Facility Allotted CCC beds

City of Thunder Bay St. Joseph’s Hospital 174 *

District of Kenora

Lake of the Woods District Hospital 0

Dryden Regional Health Center 10

Red Lake – Margaret Cochenour Memorial Hospital 4

District of Thunder Bay

Geraldton District Hospital 7

Nipigon District Memorial Hospitals 7

Wilson Memorial General Hospital 12

McCausland Hospital 13

Manitouwadge General Hospital 0

District of Rainy River

Atikokan General Hospital 8

La Verendrye General Hospital 20 **

Emo Health Centre 0

Rainy River Health Centre 0

Northern Meno Ya Win Health Centre 8

Total 263 *St. Joseph ’s Hosp i ta l CCC beds include 32 designated Hosp ice/Pa l l ia t i ve Care beds

**current l y using as acute over f low and not report ing using CCRS

Rehabilitation happens in CCC beds and the corresponding rehabilitation level of care as defined by the

RCA, is Short-Term Complex Medical Management and Long-Term Complex Medical Management.

Short-Term Complex Medical Management rehabilitation in CCC is less intense with up to one hour of

rehabilitative activities, based on the client’s medical condition and tolerance for rehabilitation. Clients

have functional goals of stabilization, maintenance, and progression. Required nursing care is more than

three hours per day. The RCA work acknowledges rehabilitation in CCC beds. As discussed, regional

hospitals who believe they have a significant level of rehabilitation taking place in CCC beds may apply

the “Bedded Level of Care Toolkit” created by the RCA and determine if beds should be re-designated.

However, due to the small hospital base funding formula, the majority of hospitals in the North West

LHIN would not be incentivized to engage in this exercise, as it would increase their reporting demands

for a very small number of beds without an increase in overall funding. The exceptions are SJH and Lake

of the Woods District Hospital in Kenora who could engage in this exercise if needed, as they are not

classified as small hospitals.

Within the North West LHIN, SJH in Thunder Bay has the majority of designated CCC beds. These beds

primarily provide services designed for seniors and those with medically complex and extensive care

needs. The majority of referrals to SJH CCC are from TBRHSC, the acute tertiary centre, where the most

complex, acute, medical cases are treated. Currently, SJH provides CCC care on three inpatient floors.

Each of these floors (except Hospice/Palliative Care) aligns with a RCA bedded level of care. One floor

provides a rehabilitative level of care: the 54-bed Geriatric Assessment and Rehabilitative Care unit. This

floor is designed for clients in need of a short-term admission (60 days or less) with the goal of discharge

home with increased independence and functionality. The Geriatric Assessment and Rehabilitative Care

unit serves the frail senior population, primarily of Thunder Bay, and includes the Assess and Restore

54

philosophy of care. Clients admitted to these beds receive daily therapy, at a level of care appropriate to

their needs, consistent with the RCA rehabilitation level of care definition.

In addition to the Geriatric Assessment and Rehabilitative Care Unit, SJH has a Medically Complex floor

with 60 beds, providing Short and Long-Term Complex Medical Management. The clients in these beds

are provided with both rehabilitative care and medical management with the goal of discharge home. The

clients typically require a longer length of stay (up to 90 days or longer) and a lower intensity of

rehabilitation (approximately three times per week). The remaining designated CCC beds at SJH are

utilized for the hospice/palliative care clients (32 beds), and transitional care for clients designated ALC

for LTC or housing (28 beds). The clients on these floors require and receive highly specialized

rehabilitative care from an interdisciplinary team including key professions of nursing and respiratory

therapists. In addition to the rehabilitation team of physiotherapy (PT), occupational therapy (OT),

speech-language pathology (SLP), dietitian, social work as discussed in other rehabilitative care

definitions, the role of nursing and respiratory therapist is essential for these clients. The Long-Term

Complex Medical Management program provides ongoing support to clients with ventilators, complex

wound care needs, and palliative needs for diagnoses other than cancer. The specialized skill sets and

rehabilitative culture of both respiratory therapists and nurses is available at St. Joseph’s Hospital and a

potential resource for the entire North West LHIN.

To optimize coordinated care and support, co-location of like populations took place in December 2016.

All seniors’ care is provided on a single floor and all medically complex and extensive services is

provided on another floor. This physical change enables these units to increase their specialization and

improve support to regional care providers. Each floor aligns with the RCA bedded level of care

definitions, ensuring the same level of rehabilitative care is provided at SJH. The change will also

facilitate future changes to ensure the continuum of care is provided, from inpatient to outpatient services,

and vice versa, with the goal of including regional service providers.

Complex Continuing Care Bed Utilization and Regional Needs

As previously noted, current utilization of inpatient CCC beds is variable across the North West LHIN

with many facilities using beds for clients who have been designated ALC to LTC. To complicate matters

further, not all facilities track the utilization of their CCC beds. In order to better use these resources, a

gap analysis was undertaken to assess current practice and identify what is required to implement the

RCA bedded level of care definitions (Table 3, 4 and 16). It was evident that rehabilitative care is

occurring in acute care beds in many of the small, rural hospitals and this is the only exception to full

alignment with the RCA levels of rehabilitative care definitions throughout the North West region.

Education regarding the definition of CCC and the rehabilitative care definitions was completed during

regional stakeholder engagement sessions.

The following tables (Tables 18 and 19) compare reported CCC bed utilization to funded beds. Thunder

Bay reports higher number of beds compared to allocated beds as bed occupancy is consistently higher

than 90%. Since 2013/14, Kenora and Dryden stopped reporting CCC utilization of the 20 beds in

previous CCC bed allocations, and Fort Frances did not report any CCC utilization of their 20 beds since

2014/15. However, Table 19 indicates the number of CCC patient days provided for clients from these

IDNs (Kenora 2698; Rainy River 1874) before reporting stopped and it is assumed that the need for

55

rehabilitative care at this level continues. These facilities now use acute care beds to treat clients requiring

this level of care and/or their clients are treated in other IDNs such as the City of Thunder Bay. The City

of Thunder Bay also provides this CCC-level rehabilitative care to people throughout the North West

LHIN. There was also a significant increase in CCC patient days since 2014 for clients from the City of

Thunder Bay, District of Thunder Bay and the Northern IDN.

It is important to note that within this data set, CCC patient days are calculated for clients admitted and

discharged within the year, which under-represents the actual usage. In small communities such as the

District of Thunder Bay with only 28 discharges in 2013 and LOS from 365 to 2872 days, the low

volumes of actual clients will have a greater effect on the apparent accuracy of the data and may explain

the low volumes noted in 2012 and 2013.

Table 18. CCC Bed Utilization Data 2013-2015 by IDN

CCC Patient Days 15-16

Actual

Beds**

Bed

Variance

*** IDN Community Allocated Beds 2013/14 2014/15 2015/16

City of Thunder Bay Thunder Bay 142 50846 50917 50012 151 9

Kenora

Kenora 0 0 0 0 0 0

Dryden 10 0 0 0 0 -10

Red Lake 4 1457 1362 1460 4 0

Rainy River

Atikokan 8 1995 2410 2262 7 -1

Fort Frances 20 182 0 0 0 -20

Emo 0 0 0 0 0 0

Rainy River 0 0 0 0 0 0

District Thunder Bay

Marathon 12 2082 2403 2892 9 -3

Terrace Bay 13 1416 2694 1690 5 -8

Geraldton 7 2544 2453 2474 7 0

Nipigon 7 2544 2520 2541 8 1

Manitouwadge 0 0 0 0 0 0

Northern Sioux Lookout 8 1491 2000 2044 6 -2

Total Bed Days 231 64557 66759 65375 197 -34

*Source: CIHI CCRS, Thunder Bay excludes Hosp ice/Pa l l ia t i ve Care and Temporary Transi t iona l Care

**90% Occupancy; ** * Actua l f rom Funded

56

Table 19. CCC LOS (in days) on Discharge with Home IDN based on Postal Code

IDN 2011 2012 2013 2014 2015

City of Thunder Bay 57,089 54,326 51,945 69,666 72,943

District of Kenora 2,698 441 37 124 577

District of Rainy River 2,232 1,874 360 605 186

District of Thunder Bay 37,279 13,123 6,797 22,424 22,460

Northern 3,591 3,613 3,522 8,133 5,471

Out of North West LHIN or Unknown 480 91 702 434 17

North West LHIN 103,369 73,468 63,363 101,386 101,654

Source: In te l l ihea l th , Ontar io , 2016

Table 20 compares current bed use with expected bed use by 2025. Based on expected, it is forecasted

CCC bed requirements will decrease by 96 beds for the North West LHIN, with the most significant

decrease in the City of Thunder Bay. The expected bed use includes bedded levels of care for

Activation/Restoration and Complex Medical Management (Short-Term/Long-Term) but does not take

into account current ALC for LTC use of CCC beds and excludes palliative care.

Table 20. Current and 2025 Forecast of CCC Days by IDN

IDN Community

15-16 Actual

Beds 90%

Occupancy

2025

Expected

Days *

Expected

Beds @ 90%

Occupancy

Variance

Expected

from

Actual

City of Thunder Bay Thunder Bay 151 19,350 58 -92

District of Kenora

Kenora 0 4,152 13 13

Dryden 0 1,656 5 5

Red Lake 4 725 2 -2

District of Rainy

River

Atikokan 7 532 2 -5

Fort Frances 0 1,743 5 5

Emo 0 312 1 1

Rainy River 0 493 1 1

Marathon 9 523 2 -7

57

IDN Community

15-16 Actual

Beds 90%

Occupancy

2025

Expected

Days *

Expected

Beds @ 90%

Occupancy

Variance

Expected

from

Actual

District of Thunder

Bay

Terrace Bay 5 451 1 -4

Geraldton 7 817 2 -5

Nipigon 8 568 2 -6

Manitouwadge 0 366 1 1

Northern District Sioux Lookout 6 1,825 6 -1

Total 197 33,513 101 -96

*Preyra So lu t ions Expected Days

The following table includes the addition of ALC to rehabilitation and CCC from TBRHSC for fiscal

years 2013/14, 2014/15, and 2015/16. Adding this data to the actual SJH data gives a more accurate

prediction of the CCC needs and confirms reports that SJH is over bedded for CCC.

Table 21. SJH – 2013-2016 Summary of Current CCC and Rehab Patient days and Beds (excluding

Palliative Care and ALC)

Bed Type Allott

ed

Actual Reported 2013/14 Actual Reported 2014/15 Actual Reported 2015/16

Patient

Days

Bed

#

Bed # at

95%

occupancy

Patient

Days

Bed

#

Bed # at

95%

occupancy

Patient

Days

Bed

#

Bed # at

95%

occupancy

CCC 142 27,541 76 80 32,374 89 94 36,702 101 106

Rehab 50 15,783 43 46 16,766 46 48 16,098 44 46

Total 192 43,324 119 126 49,140 135 142 52,800 145 152

TBR ALC to CCC 3,402 9.3 9.8 6,847 18.8 19.8 5,002 13.7 14.4

TBR ALC- Rehab 1,814 5.0 5.3 1,208 3.3 3.5 1,400 3.8 4.0

Total CCC 30,943 85.3 89.8 39,221 108 114 41,704 115 120

Total Rehab 15,597 48 51.3 17,974 49.3 51.5 17,498 47.8 50

Grand Total 48,540 133 141 57,195 157 165.5 59,202 162 170

Note 1 : Al l Actua l pat ien t days and beds exclude hosp ice/pa l l ia t i ve care and ALC days as reported in access to care reports

The various data sources present inconsistent information related to regional use of CCC beds in the

North West LHIN. The service delivery by specific health service providers (HSP) has changed over the

years making interpretation of the results very difficult.

The number of rehabilitation beds required in the North West LHIN will remain relatively stable at 50

beds, and with predictions (Table 13) indicating the need for an increase of approximately 5 beds in 2025.

The actual number of CCC beds required in the City of Thunder Bay appears to be 120 taking into

consideration ALC days to CCC at TBRHSC. The current number of beds at SJH less Palliative Care

beds is 142. It would appear that SJH is overbedded by 22 beds if the ALC to LTC and ALC to other

58

destinations were placed in their designated levels of care. The opportunity for clients at TBRHSC who

would benefit from rehabilitation, especially geriatric rehabilitation, to come to SJH requires a firm plan.

It would benefit both organizations under the current funding formula and the North West LHIN overall.

As previously stated, more accurate reporting and data collection is needed to determine where patients

meeting CCC classification are admitted and treated within the different hospitals within the North West

LHIN. This data would provide more definitive information than can be extracted from available data

sources. Table 4 provides an estimate from rehabilitation clinicians but future provincial reporting

requirements must be determined. There is simply not enough available data to make assumptions or

conclusions regarding regional bed numbers and siting from existing data.

Complex Continuing Care bed funding is also dependent on the care needs of a client and resource use.

Since 2012-13, there has been an increase of 6,922 patient days (non-weighted) attributed to complex care

inpatient services in the North West LHIN. St. Joseph’s Care Group total patient days stayed relatively

stable at 59,000 days from 2012 to 2014 but has increased to approximately 70,000 since then. Resource

Utilization Group Weighted Patient Day (RWPD) Case Mix Index (CMI), a relative measure of resource

use, has declined in the North West LHIN from 0.9658 (2012) to 0.9290 (2016). St. Joseph’s Care Group

has reported a decline from 1.0288 (2012) to 0.9893 (2016). These changes affect HBAM funding and are

directly related to increases in ALC rates at SJH and throughout the North West LHIN. There is an

opportunity to increase funding in the future by ensuring the appropriate clients are referred and admitted

to SJH. Currently, CMI at SJH without ALC to LTC clients is approximately 1.06.

Table 22. Resource Utilization Group Case Mix Index and Patient Days (weighted and non-weighted)

Year

North West LHIN St. Joseph’s Care Group

RWPD

CMI

RWPD

Patient

Days

Patient Days

(non-

weighted)

RWPD CMI

RWPD

Patient

Days

Patient Days

(non-weighed)

2015-16 0.9290 80,083 86,200 0.9893 70,106 70,867

2014-15 0.9141 78,300 85,660 0.9646 67,344 69,818

2013-14 0.9494 69,135 72,818 1.0017 59,205 59,107

2012-13 0.9658 73,161 75,748 1.0288 61,855 60,122

Source: CIHI e -report Sept 1 , 2016

Alternative Level of Care (ALC) on CCC and Strengths, Gaps, and Recommendations

As with the other inpatient beds, ALC rates impact CCC. In the North West LHIN, the ALC rate within

CCC is 41% (2015/16) with some facilities reporting ALC rates in excess of 90% (Table 23). In 2015/16,

SJCG reported a 41% ALC rate with 42 beds allocated for ALC (excluding hospice/palliative care and

temporary transitional care) (Table 24).

59

Table 23. North West LHIN CCC ALC Rate

IDN Facility 2013/14 2014/15 2015/16

City of Thunder Bay St. Joseph's Hospital 46.0% 45.0% 41.0%

District of Kenora Red Lake 0.0% 0.0% 0.0%

District of Rainy River Atikokan 77.8% 61.0% 91.8%

District of Thunder Bay

Geraldton 75.5% 77.7% 79.3%

Wilson Memorial 35.6% 37.8% 21.3%

McCausland 0.0% 0.0% 14.7%

Northern District Sioux Lookout 93.3% 98.7% 90.4%

North West LHIN 44.8% 44.0% 40.8%

Source: WTIS Access to Care

Table 24. St. Joseph’s Care Group CCC ALC Rate

2014/15 2015/16

CCC ALC Days* 18,051 14,063

ALC Beds (90% occupancy) 54 42

Source: SJCG; *excl . Hosp ice/Pa l l ia t i ve Care and Temp. Transi t iona l Care

In all of the IDNs, the majority of ALC clients are waiting for LTC. There has been a recent increase in

the number of Extended Care beds in Atikokan but the issue continues throughout the region. Within the

City of Thunder Bay, the expectation is the number of clients waiting for LTC will temporarily decrease

with the Hogarth Riverview Manor expansion opening in 2017 and the announcement that Bethammi

Nursing Home will remain open providing a net increase of 148 LTC beds to the system. However, the

demand for LTC homes continues to grow.

However, there will continue to be clients waiting for supportive and accessible housing units in Complex

Continuing Care. This has been identified as a concern in all IDNs. In the City of Thunder Bay, clients are

ALC for supportive housing at both SJH and TBRHSC. The wait lists remain lengthy for Sister Leila

Greco, PR Cook, Jasper Place, HAGI, and BISNO as well as direct funding opportunities for support and

accessible, affordable housing with The District of Thunder Bay Social Services Administration Board.

Little movement occurs for years. Initiatives in the North West region to combine clients needing

supportive housing with individuals requiring low-income housing needs have been challenged by low

volumes and safety concerns. Client and healthcare professional stakeholders indicate vulnerable clients

60

do not feel safe in this mixed environment. The North West LHIN will be required to develop a plan to

provide more supportive housing opportunities for the clients affected by the lack of an affordable,

accessible housing supply. There is also an opportunity to provide a higher level of support to those in the

community as well as in the current supportive housing programs to support aging in place and reduce the

reliance on LTC when care needs increase.

In addition to causing issues with client flow, ALC clients impact funding formulas. Clients who are

awaiting any alternate level of care impact the RWPD CMI significantly, as they require and receive less

extensive medical services and/or rehabilitation than CCC clients.

The ALC issue presents itself differently across the province, and one solution will not meet the needs of

all LHINs. The North East and North West LHINs experienced similar rates in 2014/15 but the North

East LHIN rate has remained steady, whereas the North West LHIN has seen rapid growth. North Simcoe

Muskoka had a similar rate to North West LHIN in 2104/15, yet is experiencing a decline in the ALC

rate, year over year. The Hamilton, Niagara, Haldimand, Brant LHIN is experiencing the same trend as

the North West LHIN, where the ALC rate is increasing. Solutions at the community and environment-

level will be needed in each LHIN and is beyond the scope of a single HSP. The high rate of ALC within

CCC beds makes current evaluation more challenging, as it is difficult to get an accurate view of

appropriate use and need of CCC beds in each location. As each LHIN develops strategies to address

ALC rates, it would be helpful to share ideas on how to stop the continual increase of clients being

designated as requiring LTC, since these clients make up the majority of ALC clients in any given LHIN.

The Ontario healthcare system strives to provide the right care, in the right place, at the right time. The

ALC issue exemplifies, at times, the lack of early intervention or delay in accessing rehabilitative care for

those in need, which results in clients presenting in the emergency department requiring acute care when

other preventative strategies may have helped avoid this presentation and/or admission to acute care.

Summary

The goal to provide the right care, in the right place (as close to home as possible), at the right time is

limited in the North West LHIN by the relatively small population over a vast geography. The delivery of

inpatient rehabilitative care is challenged by the sheer economies of scale, which impact the availability

of rehabilitation beds, LTC homes, supportive housing, and health human resources. Despite these issues,

the current recommendation is to maintain the number and location of rehabilitation and CCC beds

throughout the North West LHIN, while making efforts to improve the appropriate use of these beds

through strategies to address the ALC issues with all stakeholders and partners; continue efforts to

achieve efficiencies regarding lengths of stay, and develop a strategy to build capacity to provide

rehabilitative care as close to home as possible. Within the North West LHIN, there is potential for

improved care with the implementation of an integrated system.

61

Outpatient and Community Services

In order to support and improve utilization of resources at all levels of rehabilitative care, it is essential to

identify outpatient and community-level services as an essential part of the continuum of care. The term

outpatient and community services will be used interchangeably to describe care clients receive in private

clinics, community-based facilities, and hospital-based outpatient services. The term home care will

specifically refer to care provided in the home through CCAC services.

Outpatient/ambulatory rehabilitative care is not a universally insured service under the Canada Health

Act, and in the past few years, there has been an erosion of the number and scope of hospital-based

outpatient rehabilitation programs and associated NIHB services for Aboriginal people, in an effort to

achieve cost containment. Existing outpatient services require a review to accurately identify current

utilization trends and opportunities for enhanced service delivery. The RCA is currently developing and

piloting a process to implement a provincial minimum data set for outpatient services. This data collection

system aims to ensure care provision across the province meets minimum standards for clinical outcomes,

client satisfaction, access and transition, and financial responsibility.

In addition to the minimum data set, the RCA has standardized progression and maintenance definitions

for community-based rehabilitative care (Appendix B). Adherence to these definitions will ensure future

service delivery in outpatient/community settings will be consistent, with all clients being treated

according to a defined progression or maintenance level of care, providing clarity for clients, families, and

referring professionals regarding expectations of care. The RCA definitions framework outlines what

resources should be available within each level of community-based rehabilitative care. The definitions

developed by the RCA, are specifically designed to characterize care for clients with restorative potential;



Recommendation #3: Facilitate adherence to best practices for rehabilitative care to

improve client-centred care

Recommendation #4: Enhance utilization of innovative technologies to improve access

to rehabilitative care services closer to home, particularly in remote and underserviced

areas

62

described by the RCA as “reason to believe that the clients condition is likely to undergo functional

improvements and benefit from rehabilitative care”.

Community-based rehabilitative care can be provided in an individual or group format, in a hospital-

based or community clinic or within the client’s home. In order to meet the eligibility criteria for

outpatient/community therapy as defined by the RCA, care must be overseen by a regulated healthcare

professional. Wellness-focused health promotion and prevention programs not supervised by regulated

health professionals are beyond the scope of the definitions framework for community levels of

rehabilitative care. Although these programs play an important role preventing health decline and

maintaining the health of clients on a rehabilitative care journey, they are not included within the

definitions framework, or the rehabilitative care review. Those programs will be considered when

reviewing the continuum of care required to support clients.

The community-based levels of care include:

• Progression: Within a progression level of care, the goal of therapy is to provide assessment and

time-limited treatment through a single service of coordinated interprofessional approach. This

may include restoring or maximizing function, adapting the home environment to support

reintegration to the community, supporting transitions from and preventing admission to acute

care, and providing opportunities to learn and practice in a familiar environment. Progression

level of therapy is typically for clients following acute episodes or worsening of symptoms. The

overall target of a progression level of therapy is to improve, develop, or restore function that has

been lost or impaired.

• Maintenance: A maintenance-level of community care is designed to prevent functional decline

or injury and to maintain functional performance. Typically, clients who are seen in a

maintenance level of care require an individual assessment and treatment program with periodic

assessment and oversight of care plan. Clients in this level of care generally have a prolonged

condition requiring intervention to prevent a decline in functional status and/or allow them to

remain at home. Individuals within this level of care frequently participate in community-based

group interventions such as falls prevention exercise classes to promote ongoing maintenance.

Presently, publicly-funded outpatient and community services in the North West LHIN are primarily

provided through the North West CCAC, hospital outpatient facilities, Victoria Order of Nurses (VON),

and a few private physiotherapy (PT) clinics in some IDNs. All clinics operate using specific service

eligibility criteria; however, an examination of how to best utilize services to enhance overall system flow

is required. There are six primary publicly-funded platforms through which clients receive

outpatient/community rehabilitative care services. These platforms include:

5. CCAC for in home therapy.

6. Hospital-based outpatient programs.

7. Specialized outpatient service programs (e.g. Neurology, Regional Joint Assessment Centre, Asthma Clinic, etc.).

8. Designated Community Physiotherapy Clinics (CPC).

63

9. Community Health Clinics (CHCs) and Family Health Teams (FHTs).

10. Alternative Payment Plan/Ontario Health Insurance Program (OHIP) - funded Physiotherapy Clinics. (Note these clinics are not included in the table below).

The following table (Table 25) defines the different platforms as outlined in the “Physiotherapy Reforms

in the North West LHIN”. It is noted however, this table does not include hospital-based outpatient

programs or the Alternative Payment Plan/OHIP funded programs.

Table 25. Overview of the Physiotherapy Reform in the North West LHIN (updated June 2014)

Stream 1

Exercise & Falls

Prevention Classes

Stream 2

In-Home PT Service

Stream 3

Long Term Care Homes

Stream 4

Publically Funded PT

Clinics

Stream 5

Primary Care Settings

• No cost to

participants

• No MD referral

needed

• No cap on number

of classes a participant can

attend • Screening by lead

agency

• Combination of in-

person and v/c

programming • Per/LHIN

allocating based on

population

distribution (seniors)

• Locations:

• Dryden

• Patricia

Region Senior Services

Incorporated

• All other

communities in North West

LHIN

• Victorian

Order of Nurses (VON)

• NW CCAC as central

intake

• New clients assessed

for and provided with

PT services as per CCAC criteria

• For previous clients

receiving DPC support:

• All clients

previously

receiving 1:1 PT services in

retirement homes

and supportive housing were

assessed for

ongoing care • Clients meeting

CCAC criteria for

PT continue to

receive; others d/c and/or transitioned

to exercise and

falls classes.

• LTCHs went through

RFP process and/or

retained previous

providers • Change in service

delivery with PT focus

on 1:1 care

• $750/patient bed for PT services (global

allocation)

• ADP included in PT

funding envelope • Additional funding for

exercise classes under

alternate funding

envelope.

• Previously no DPCs in

North West LHIN

• Funding based on episode

of care (patient-based

funding) • $312/episode of care

(EOC)

• MD referral required

• No lower/upper limit on

number of visits • No cap on number of

EOCs/person/year

• Each EOC must be a new

client concern with new

referral • Assessment/goals/

discharge plans must be

submitted including

resources

recommended/referred to

on discharge

• Contact with MOHLTC with reporting criteria

detailed

• Per/LHIN allocation based

on population distribution (seniors).

• Locations

• Thunder Bay

• Fairway

Physiotherapy

• Closing the Gap

• Outside Thunder Bay

• Wilson Memorial General Hospital

• Lake of the Woods

District Hospital

• Red Lake Margaret

Cochenour Memorial Hospital

• Dryden Regional

Health Centre

• Atikokan General

Hospital • Sioux Lookout Meno

Ya Win Health

Centre

• Not yet announced

• Priority is under-

served population

• Requirement to

intake ‘un-rostered’

patients • Direct administration

by MOHLTC

64

Table 26 demonstrates the relatively small number of community-based rehabilitation program options in

the North West LHIN. It is important to note although only two exercise programs and two Falls

Prevention programs are reported, the VON Exercise and Falls Prevention program services 14 sites

across the North West LHIN. It is also important to note although three CPCs are reported in this table,

there are actually eight CPCs in the North West LHIN, as well as one Community Health Clinic which

offers PT services and two publicly-funded clinics with OHIP alternative payment plans not noted on this

table. In addition to these programs, some family health teams offer community-based exercise and

chronic disease management programs. However, these programs are not within the scope of

rehabilitative care as they do not require service provision from a regulated healthcare provider.

Table 26. Number of Community-Based Rehabilitation Programs by LHIN

LHIN

# Community Based CHC

CHC – In

home

Exercise

Program

Community Physio

Clinic

Community

Program

Community

Rehab

Falls

Prevention Total

1 Erie-St. Clair 13

2 South West 9 1 31 2 7 50

3 Waterloo Wellington 12 12

4 Hamilton Niagara Haldimand Brant 5 2 1 30 1 40 79

5 Central West 4 4

6 Missisauga Halton 2 11 1 5 19

7 Toronto Central 18 24 14 56

8 Central 25 27

9 Central East 26 27

10 South East 2 2

11 Champlain 14 10 24

12 North Simcoe Muskoka 10 10 2 22

13 North East 3 13 1 20

14 North West 2 3 2 7

Total 52 2 6 214 13 2 73 362

Source : RCA Al ignment Report

65

Throughout Ontario, there has been a demonstrated lack of available data regarding outpatient services.

This limitation impacts the quality and reliability of data obtained for community rehabilitation programs

in NWO. In order to determine the amount of care provided in the community, programs funded by the

North West LHIN or Ministry of Health and Long-Term Care were surveyed using the RCA

Community Levels of Care Mapping Tool (Appendix J). This tool summarized the amount of

care for both RCA defined levels: progression and maintenance. Table 27 provides a list of the

rehabilitation programs reported in mapping exercise. Table 28 provides a summary of the

number of visits provided by each of the different programs. All the programs report full

alignment with the RCA community levels of care definitions. The data should be viewed as an

estimate of current services, recognizing a standardized data collection system is still outstanding

for outpatient services. This specific limitation is the second focus of the RCA outpatient-

working group. A proof of concept for a minimum data set for outpatient services is currently

underway. This minimum data set will include measurements in four domains: Client/Caregiver

Experience, Clinical Outcomes, Access and Transition, and Financial Performance.

Recommendation #5: Develop and implement data collection and evaluation systems for

quality of care monitoring and continuous quality improvement to improve resource

efficiencies for the provision of client-centred care

66

Table 27. RCA Community Mapping Tool Reported Programs

IDN Facility Name of Program Level of Care

City of Thunder

Bay

St. Joseph’s Hospital

Pulmonary Rehabilitation Progression

Community-Based Exercise Programs Maintenance

Asthma Clinic Progression and Maintenance

Outpatient Orthopaedics (Physiotherapy and Occupational

Therapy) Progression

Rheumatic Diseases Program Progression and Maintenance

Outpatient Neurology (including Neurology Day, OP physiotherapy, Occupational Therapy, and Moving on after

Stroke self management and exercise program)

Progression and Maintenance

Thunder Bay Regional

Health Sciences Centre

Outpatient Physiotherapy Progression

Hand Clinic Progression

Centre for Complex Disease Care Progression and Maintenance

Lymphedema Management Program Progression and Maintenance

Regional Joint Assessment Centre Maintenance

Intra-spinal Assessment and Education Centre Maintenance

Fairway Physiotherapy Community Physiotherapy Clinic Progression

Closing the Gap Community Physiotherapy Clinic Progression

CCAC-VON Community Exercise and Falls Prevention Classes Maintenance

CCAC in home services

In home Physiotherapy Progression and Maintenance

In home Occupational Therapy Progression and Maintenance

In home Speech Language Pathology Progression and Maintenance

District

of Kenora

Lake of the Woods District Hospital

General Outpatient Physiotherapy and Speech Language Pathology

Progression

Cardiac Rehabilitation Progression

Community Physiotherapy Clinic Progression

Dryden Regional Health Centre

Outpatient Occupational Therapy Clinic Progression

Outpatient Physiotherapy Clinic Progression

Cardiac Rehabilitation Progression


CCAC OT/PT Contracted Services Progression and Maintenance

Patrician Region Senior

Services Inc.

Falls Prevention Classes Progression and Maintenance

Community Exercise Maintenance

Margaret Cochenour

Memorial Hospital

Cardiac Rehabilitation Progression and Maintenance

Outpatient Physiotherapy Clinic Progression and Maintenance


District

of Thunder

Bay

Manitouwadge General

Hospital

Cardiac Rehabilitation Maintenance

Outpatient Physiotherapy Progression and Maintenance

Nipigon District Memorial Hospital



Geraldton District Hospital

Outpatient Physiotherapy Progression

Outpatient Occupational Therapy Progression and Maintenance


McCausland Hospital Outpatient Physiotherapy Clinic Progression and Maintenance


Hospital


Community Physiotherapy Clinic Progression and Maintenance

District

of Rainy

River

Riverside Health Care


Outpatient Occupational Therapy Clinic Progression and Maintenance

Outpatient Speech/Language Pathology Clinic Progression and Maintenance

Atikokan General Hospital



Outpatient Occupational Therapy Clinic Progression and Maintenance


Northern Meno Ya Win Health

Centre

Community Physiotherapy Clinic Progression and Maintenance



67

Table 28. Number of Community-based Rehabilitation Patients in North West LHIN

IDN Facility Name of Program Location of Program Number of Patients

City of

Thunder

Bay

Fairway Physiotherapy Community Physiotherapy Clinic Community Physio Clinic 454

Closing the Gap Community Physiotherapy Clinic Community Physio Clinic Not Provided

VON Exercise and Falls Prevention Outpatient/ Ambulatory 1300+

NW CCAC

Occupational Therapy In-Home 3551

Physiotherapy In-Home 2552

Speech/ Language Pathology In-Home 455

St. Joseph’s Hospital

Pulmonary Rehab Outpatient/ Ambulatory 2529

Community-Based Exercise Community Program 1532

Asthma Clinic Outpatient/ Ambulatory 422

Speech (Pre-school & School age) Community 6454

Orthopaedic Outpatient/ Ambulatory 9649

Rheumatic Diseases Program Outpatient/ Ambulatory 3678

Neurology Outpatient/ Ambulatory 8193

Thunder Bay Regional

Health Sciences Centre

Outpatient Physiotherapy Outpatient/ Ambulatory 4507

Hand Clinic Outpatient/ Ambulatory 330

CCDC Outpatient/ Ambulatory 161

Lymphedema (Cancer Centre) Outpatient/ Ambulatory 214

Regional Joint Assess Centre Outpatient/ Ambulatory 3593

Intraspinal Ax and Educ’n Centre Outpatient/ Ambulatory N/A

District of

Thunder

Bay

Geraldton District Hospital

Outpatient Physiotherapy Outpatient/ Ambulatory

2014/15 – 119

2013/14 – 119

Outpatient Occupational Therapy Outpatient/ Ambulatory

2014/15 – 39

2013/14 – 53

Cardiac Rehabilitation Outpatient/ Ambulatory

2014/15 – 0

2013/14 – 4

Manitouwadge General

Hospital Cardiac Rehab Outpatient/ Ambulatory

2014/15 – 1

2013/14 – 1

68



2014/15 – 174

2013/14 – 190


Hospital

Outpatient Physiotherapy (Adult) Outpatient/ Ambulatory

2014/15 – 167

2013/14 – 224

Outpatient Physiotherapy (Pediatric) Outpatient/ Ambulatory

2014-2015 – 10

2013-2014 – 19


2014-2015 – 8

2013-2014 – 7

McCausland Hospital Outpatient Physiotherapy Outpatient/ Ambulatory 320


Hospital


Community Physiotherapy Clinic Community Physio Clinic 262

Northern Meno Ya Win Health

Centre


Cardiac Rehabilitation Outpatient/ Ambulatory 26


Kenora

Lake of the Woods District

Hospital

General Outpatient Outpatient/ Ambulatory 700


WSIB/Staff Outpatient/ Ambulatory 180


Dryden Regional Hospital

Outpatient Occupational Therapy Outpatient/ Ambulatory

2014/15 - 70

2013/14 - 118


2014/15 – 470

2013/14 – 514


2014/15 – 12

2013/14 – 13

CCAC Home Care Contracted OT/PT

service In-Home

2014/15 – 467

2013/14 – 460

Community Physiotherapy Clinic Community Physio Clinic

2014/15 – 180

2013/14 – 13

Falls Prevention Patricia Gardens 5

69


Patricia Region Senior

Service Exercise Program Patricia Gardens/10 Victoria 59

Margaret Cochenour Mem.

Hospital




Rainy River

Riverside Health Care

Physiotherapy Outpatient/ Ambulatory 2050

Occupational Therapy Outpatient/ Ambulatory 246

Speech/ Language Pathology Outpatient/ Ambulatory 341

Atikokan General Hospital

Cardiac Rehabilitation Outpatient/ Ambulatory 166 (visits)

Outpatient Physiotherapy Outpatient/ Ambulatory 3352 (visits)

Community Physiotherapy Clinic Community Physio Clinic 1460 (visits)

PT CCAC In-Home 32 (visits)

Outpatient OT Outpatient/ Ambulatory 1110 (visits)

OT CCAC In-Home 107 (visits)

In addition to the lack of standardized data for outpatient services, referral patterns are non-standardized.

Most referrals are generated by primary care practitioners who may base referrals on their experience and

familiarity with a specific program, rather than matching the individual client need with the optimal

service or available publicly-funded resource. Community rehabilitation may require private payment or

extended health benefits when publicly funded options are not available. Occasionally, publicly-funded,

specialized clinics are inappropriately used when community-based outpatient programs are not available

locally. In addition, as a result of poor timely access to needed services, clients are often referred to

several programs simultaneously, with the anticipation of being admitted to the most appropriate

program. This referral method results in over-representation and inaccurate projections of the need for

services, inefficient use of resources, and ultimately leads to poor access to services due to inflated wait

lists.

In order to gain a better understanding of the publicly-funded programs available and their impact on the

regional rehabilitative care model, the six platforms of care provision were examined.

Community Care Access Centres (CCAC)

Within Ontario, publicly-funded therapy provided in the home is coordinated by CCAC. Within the North

West LHIN, CCAC services are coordinated by the North West CCAC. From a rehabilitative care

perspective, CCAC uses contracted service providers within each LHH to provide PT, OT, and SLP

assessment and treatment for clients who cannot access outpatient services as well as other in-home

support services such as personal care provided by PSWs and nursing care. There are also Nurse

70

Practitioners (NP) who provide in home palliative care services throughout the North West. The North

West CCAC’s mission is “to deliver a seamless experience through the health system for people in our

diverse communities, providing equitable access, individualized care coordination, and quality

healthcare”. From a rehabilitative perspective, this includes optimizing function, safety and independence,

providing support through healthcare transitions, and providing care following illness or compromised

health.

CCAC Utilization and Regional Needs

Congruent with the CCAC mandate, the client populations seen by CCAC therapists are clients who

require some level of therapy, but are unable to access a hospital or community-based service provider.

The results of the RCA community-based levels of care mapping tool indicate CCAC services provide

both progression and maintenance levels of care (Table 27). However, specific utilization data show the

majority of CCAC services across the province, including the North West, provide a maintenance level of

care (Table 29 and 30).

Table 29. Categorization of CCAC In-Home Services by Level of Care by LHIN

CCAC

2014/15 Categorization of CCAC In-Home Services by Level of Care

To

tal

In-H

om

e

Ser

vic

es

Pro

gre

ssio

n

Mai

nte

nan

ce

Acu

te I

n-H

om

e

En

d o

f L

ife

Oth

er

% i

n R

CA

Fra

mew

ork

Central 4,220,511 5% 82% 7% 5% 1% 87%

Central East 4,245,052 4% 81% 7% 6% 1% 85%

Central West 1,587,046 9% 71% 9% 5% 5% 80%

Champlain 3,236,990 3% 82% 8% 6% 1% 85%

Erie S. Clair 2,232,394 5% 74% 11% 9% 1% 80%

HNHB 5,241,953 8% 78% 8% 5% 1% 86%

Miss. Halton 2,480,990 8% 70% 11% 10% 1% 78%

North East 1,904,438 5% 79% 9% 6% 1% 84%

North West 919,885 6% 82% 7% 5% 1% 88%

Nth. Simcoe Musk. 1,375,659 2% 78% 8% 9% 2% 81%

South East 2,007,113 11% 78% 7% 3% 1% 89%

South West 27,192,122 5% 77% 10% 6% 2% 83%

Toronto Central 3,679,413 4% 86% 4% 4% 2% 90%

Waterloo Well. 1,987,192 10% 74% 8% 8% 1% 83%

Ontario 37,837,848 6% 79% 8% 6% 1% 85%

NW LHIN Rank 14 6% 2% 9% 9% 5% 3% (Exh ib i t 11 : 2014/15 Categor iza t ion o f CCAC in -home Services by Leve l o f Care – Champla in LHIN report by Hay Group –

Page 25)

71

Table 30. Age and Gender Standardized Services per 10 000 Population by CCAC by Service Activity Category by LHIN

CCAC

2014/15 Age/Gender Standardized Services per 10,000 Population by CCAC by Service Activity Category (SRC)

93

- M

ain

ten

ance

94

– S

upp

ort

ive

60

– A

cute

95

– E

nd

of

Lif

e

92

– R

ehab

ilit

atio

n

47

– P

lace

men

t

49

– C

on

val

esce

nt

Car

e

48

– S

ho

rt S

tay

Res

pit

e

All

Oth

ers

Gra

nd

Tota

l

Central 17,655 3,729 1,613 1,182 1,205 108 22 10 127 25,198

Central East 6,854 14,261 1,943 1,642 1,029 164 18 10 171 26,092

Central West 8,355 8,787 1,801 1,279 1,828 124 10 5 1,146 23,335

Champlain 4,502 16,088 1,960 1,400 836 192 12 19 96 25,105

Erie S. Clair 17,498 5,864 3,442 2,782 1,755 157 10 11 136 31,655

HNHB 19,070 6,010 2,725 1,623 2,689 74 18 3 111 32,323

Miss. Halton 13,173 4,592 2,379 2,577 2,032 116 13 5 140 25,027

North East 7,583 15,447 2,777 1,606 1,591 175 19 15 211 29,424

North West 20,421 10,059 2,475 1,748 2,078 107 5 10 120 37,023

Nth. Simcoe Musk. 2,875 17,713 2,226 2,217 588 170 31 22 448 26,290

South East 19,503 6,298 2,522 1,050 3,715 74 4 6 103 33,175

South West 4,992 14,622 2,585 1,539 1,425 181 7 16 233 25,597

Toronto Central 14,398 10,849 1,317 1,207 1,227 20 3 2 4,662 29,485

Waterloo Well. 15,341 5,667 2,287 2,219 2,597 111 7 4 99 28,332

Ontario 12,086 9,707 2,177 1,638 1,636 124 14 9 225 27,616

NW LHIN Rank 1 7 6 5 4 11 12 6 10 1 (Exh ib i t A5: 2014/15 Categor iza t ion o f CCAC in -home Services by Leve l o f Care – Champla in LHIN report by Hay Group – page 169)

The North West LHIN has the highest overall number of service visits per 10,000 population in the province (Table 31). The NW CCAC has a

significantly higher number of PSW visits, nursing visits, Rapid Response Nursing visits, and specialist physician office visits which may speak to

the issue of the lack of LTC capacity and the number of people waiting in the community in addition to the higher number of frail seniors in the

North West LHIN. The North West LHIN also provides the second highest NP Palliative visits and the highest number of SLP visits provincially,

most likely due to the provision of speech services in LTC homes in the North West LHIN and the lack of outpatient facility-based SLP resources

in the North West LHIN region outside of the City of Thunder Bay.

72

Table 31. Age and Gender Standardized Services per 10 000 Population by CCAC by Service Activity by LHIN

CCAC

2014/15 Age/Gender Standardized Services per 10,000 Population by CCAC by Service Activity

PS

Ws

and

Ho

mem

akin

g

Nu

rsin

g V

isit

Cas

e M

anag

emen

t

Ph

ysi

oth

erap

y

Occ

up

atio

nal

Th

erap

y

Nu

rsin

g H

ou

rly

Sh

ift

Sp

eech

Lan

guag

e

Th

erap

y

Oth

er

So

cial

Wo

rk

Nu

trit

ion

/Die

teti

c

Rap

id R

esp

on

se

Nu

rsin

g V

isit

Sp

ecia

list

Ph

ysi

cian

Off

ice

NP

Pal

liat

ive

Vis

it

Oth

er D

isci

pli

nes

Gra

nd T

ota

l

Central 17,484 4,574 1,150 1,068 290 261 283 12 9 29 19 8 10 0 25,197

Central East 18,843 4,001 1,763 438 468 291 179 21 28 15 12 13 20 1 26,093

Central West 16,428 3,481 1,055 717 246 153 173 943 18 21 20 22 9 49 23,335

Champlain 17,791 4,158 1,758 398 453 258 171 4 33 27 26 19 10 0 25,106

Erie St. Clair 21,195 6,855 1,734 478 471 422 264 18 56 27 27 49 53 7 31,656

HNHB 22,612 6,188 1,623 694 425 403 196 5 29 66 41 26 14 2 32,324

Miss. Halton 17,927 4,065 1,397 653 316 439 127 0 18 19 18 10 5 34 25,028

North East 19,257 4,646 3,447 704 591 271 222 17 85 44 27 81 31 0 29,423

North West 26,444 6,884 1,578 534 526 93 504 139 92 21 53 105 43 5 37,021

Nth. Simcoe Musk.

18,367 4,,932 1,651 289 336 258 141 356 44 50 11 14 30 8 26,287

South East 24,582 5,258 1,497 562 746 180 265 0 84 40 17 21 21 2 33,275

South West 16,200 5,382 1,952 580 485 520 180 57 84 64 39 32 19 0 25,594

Toronto Central 21,019 5,004 1,734 697 406 265 246 17 23 19 31 16 0 8 29,485

Waterloo Well. 20,507 4,652 1,428 593 483 269 160 8 86 63 30 36 18 0 28,333

Ontario 16,364 4,833 1,649 626 418 301 205 72 40 35 25 24 16 8 27,616

(Exh ib i t A5: 2014/15 Categor iza t ion o f CCAC in -home Services by Leve l o f Care – Champla in LHIN report by Hay Group – page 167

Within the City of Thunder Bay, CCAC is able to provide daily access to OT, PT, SLP, SW, and dietitian services; though, the availability of

therapists in each discipline varies across the region. Community Care Access Centres endeavour to ensure access to all rehabilitative care

disciplines; however, service is limited due to economies of scale and small volume demands over a large geographical expanse. This limits the

ability to have local providers at each LHH and results in the necessity of therapists travelling long distances to provide care across the North West

LHIN. The ability to recruit home care therapists within the City of Thunder Bay has improved over the last three years but recruitment for the

part-time positions in other IDNs continues to be problematic. Recent partnerships with hospitals and publicly-funded children’s service providers

have created the ability to hire local SLPs and OTs in small communities such as Red Lake and Sioux Lookout by combining resources. Sharing

therapists between communities is an effective way to ensure available services within the community each week to be able to meet the projected

demand for in-home services (Table 32) and benefit the client care experience.

73

Table 32. Actual and Expected Home Care Services by IDN

2013/14 2025 Forecast

Long stay Home Care Clients* Other Home Care Clients† Long Stay Home Care Clients* Other Home Care Clients†

NW LHIN Integrated District

Networks and Local Health Hubs Actual Expected

Actual-

Expected Actual Expected

Actual-


Actual-


Actual-

Expected

LSHCC

Expected

%

OHCC

Expected

%

District of Kenora Total 59,108 89,137 -30,029 33,123 41,906 -8,783 75,731 113,853 -38,122 40,436 51,673 -11,237 27.7% 23.3%

District of Rainy River Total 35,329 47,145 -11,816 13,546 21,306 -7,760 39,100 53,730 -14,631 15,895 23,959 -8,064 14.0% 12.5%

District of Thunder Bay Total 26,296 32,565 -6,269 14,033 16,221 -2,188 43,750 47,306 -3,556 18,170 21,556 -3,386 45.3% 32.9%

City of thunder Bay Total 459,505 294,405 165,100 181,307 133,523 47,784 517,412 335,739 181,673 205,384 150,914 54,470 14.0% 13.0%

Northern Total 4,612 24,653 -20,041 4,153 13,109 -8,956 7,152 33,124 -25,972 5,341 17,037 -11,696 34.4% 30.0%

Grand Total 584,850 487,904 96,946 246,462 226,064 20,098 683,145 583,753 99,392 285,227 265,139 20,088 19.9% 17.3%

Sources: HCD 2013/14, NW LHIN Popula t ion Data

Note : Expected se rv ices are ca lcu la ted a t provinc ia l average use per cap i ta , ad justed for age.

*c l ien ts whose in i t ia l service goa l was “ in home main tenance” or “ in home long stay”

†cl ien ts whose in i t ia l service goa l was “ in home acute”, “ in home rehab i l i ta t ion” or “ in home end o f l i fe ” . Excludes cl ien ts whose in i t ia l se rv ice goa l set t ing was not in home.

74


Within the rehabilitative care journey, CCAC plays an important role in the recovery and return to

independent functioning. It has become essential CCAC services are connected directly to inpatient care

facilities in order to ensure a smooth transition between care providers and service delivery. Presently,

there are challenges when clients transition between facility-based service providers and CCAC

community service providers, similar to the identified challenges when clients transition between

hospitals. During stakeholder consultation (outside the City of Thunder Bay), the need for improvement

in client transitions were identified in the following areas: communication between service providers at

handover, process and timeliness of home safety assessments, availability of rental equipment at the LHH

level, and knowledge of available community services across the region and across the rehabilitative care

spectrum.

Despite challenges, current strategies for better transitions were identified. Many stakeholders identified

the addition of a CCAC care coordinator at team rounds and discharge conferences has had a positive

influence on these transitions. Currently, hospitals have access to the CCAC client information portal to

confirm if a client was receiving CCAC services prior to admission. This helps ensure clients are

reconnected with CCAC in-home service at discharge. In addition, in some smaller communities, the

same department or even the same therapist provides care at the inpatient, home care, and outpatient

phases. In these communities, issues with handover and communication are non-existent, resulting in

seamless care. This was clear in Dryden, where the Dryden Regional Health Centre is the service provider

contract for CCAC OT, PT, and SLP services. Therapists are able to access Meditech, the same electronic

medical record for inpatient hospital stays, to obtain background medical and care information; are able to

easily communicate with the inpatient therapist who has cared for the client; and, in turn, are able to

easily communicate with the therapist they are transitioning the client to in outpatient services.

Furthermore, there is no barrier to transition the client to the appropriate level of service. Clients are

transitioned to the most appropriate level of service for their care when they are ready.

75

The issue of client home safety assessments was a recurrent and frequent theme with a variety of

contributing factors. Firstly, a lack of local OTs, especially within the District of Thunder Bay, limits the

timeliness of the safety assessments and equipment recommendations. Despite the fact that it is the

responsibility of the “owner” of the patient at the time of discharge to ensure safe discharge, CCAC is

often filling the gap and completing these safety assessments. The CCAC service provider for the District

of Thunder Bay communities is based in Thunder Bay and visits every two weeks. This may result in

longer than required hospital stays, if clients are unable to return home until the safety of their home can

be assessed. Consequently, PTs complete many components of the home assessment such as stairs, toilet

and tub transfers, car transfers, and in-home mobility with the client and make temporary equipment

recommendations until such time a formal and complete home safety assessment can be completed by the

OT. In some low risk cases, this results in earlier discharge and good use of available resources. If a client

is deemed to be very high priority and needs to get home in a hurry, CCAC indicates additional therapist

visits can be arranged before the two weeks.

Secondly, the process of home safety assessments needs to be outlined and clarified. Stakeholders

acknowledged their local processes, but these were inconsistent across the region. The need for an

electronic referral initiated at the hospital for the CCAC assessment and rental equipment was clear and,

although the actual person completing this process varied from site to site, this was not the issue. It was

also identified either healthcare professionals or CCAC hospital case managers could initiate this in

Thunder Bay before repatriation back to the local LHH. The concern raised was how a client could attend

a home safety assessment with a CCAC service provider while being a hospital inpatient. If the client

safety risk is low to medium, the client’s discharge was coordinated between the hospital and CCAC to

occur at the time of the home safety assessment. There is an understanding if the environment is not safe,

the client would need to return to the hospital to await home renovations, equipment or further functional

ability. This process was identified, but the timing, coordination, and assessment of client risk between

the three facilities involved (sending, receiving, and CCAC) varied. In many cases, clients are discharged

to their LHH for a home safety assessment with the understanding this process would occur prior to their

discharge home. However, occasionally local providers assess the client’s risk level to be low and the

client is discharged home to await the formal home assessment. This is frustrating for both sending and

receiving service providers and perceived as risky and inefficient use of resources respectively. The gaps

for home safety assessments in the North West LHIN are the cases where clients are medium to high risk

for safe discharge home or where an assessment is required to determine appropriate equipment to access

the home such as a porch lift, ramp, or bathroom renovations. In these cases, the client may be permitted a

leave of absence from the hospital to attend the home safety assessment with the CCAC service provider.

These situations are much more complicated when clients do not have family support to transport them to

the home assessment or for clients who live outside the immediate area of the hospital but still within the

hospital catchment area, such as Rossport for Terrace Bay, Ignace for Dryden, and Kakebeka Falls for

Thunder Bay. Clients are encouraged to use available transportation options such as Handi-transit, taxis,

or Ambutrans, as appropriate, and these complicated situations require discussion and planning with all

parties involved, including the discharge planning team and the CCAC coordinator. It is recommended

that the involved facilities within the North West LHIN have further communication and clarification of

processes in these uncommon situations.

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Thirdly, the availability of local equipment impacts the home safety assessments. Often, different types of

equipment need to be trialed with a client in their home environment to determine appropriateness. Some

hospital departments have limited rental equipment. The current vendors for rental equipment are based

in Thunder Bay, Fort Frances, Kenora, and Dryden and in these communities equipment is available each

day of the week. However, in small communities such as Red Lake, Atikokan, Nipigon, Terrace Bay,

Marathon, Geraldton and Manitouwadge, equipment delivery is only twice a week. As a result, “best

guess” equipment is often arranged prior to the client discharge. For these communities, it was identified

this could often be done in Thunder Bay before the client transitions back to their LHH. If a client is

deemed to be very high priority and needs to get home in a hurry, rush equipment rental can be arranged.

In addition, home care therapists often arrange to meet with the vendor in the community at the time of

the visit to assist with complicated equipment. These scenarios exemplify the need for communication

between service providers at the time of client transitions.

Lastly, similar to hospital-to-hospital transitions and inpatient-to-outpatient transitions, there is room for

improved communication between providers at time of transition from hospital to CCAC, especially in

IDNs outside the City of Thunder Bay and between IDNs. At times, medical information such as

diagnosis, weight-bearing status, physician orders, and surgical reports are missing, requiring in-home

therapists to take extra time to ensure effective service efficiently on first contact with the client. Other

identified areas of concern regarding communication include: the reason for the referral or safety

assessment, specific concerns, and availability of local resources. Home care direct service providers

receive a therapy report with the referral provided by the CCAC case manager. Direct service providers

do not currently have access to the electronic medical record from the hospitals unless they also work for

the hospital and are within the client circle of care. Case managers at CCAC have access to the EMR but

do not always provide the service provider with the profession-specific level of details required, such as

recently completed assessments, physical status on discharge, equipment trialed and recommended,

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splinting trialed and recommended, and continence. These gaps in information and duplication of

assessments result in inefficiencies in the system. Planning for successful client discharge and community

reintegration requires knowledge of local community resources, which varies significantly throughout the

North West LHIN. Local resources should be understood and clarified at the time of these transitions in

order to ensure consistent messaging, ultimately improving the client experience. One major CCAC

service provider recently underwent a series of prospective safety analyses to improve the completeness

of relevant rehabilitation information required for quality, efficient client care at this time of transition.

Administrative staff screened referrals to ensure relevant information was complete and retrieved missing

information prior to the therapist receiving the referral. This was also an opportunity for education with

CCAC case managers. This cycle of continuous quality improvement resulted in improved information

transfer completeness and efficiency, confirmed by a recent random chart audit. Improvements in

documentation accuracy and consistency within the hospital EMR and targeted training with CCAC case

managers, have potential to improve the efficiencies at client transitions.

In order to solve some of these issues and to improve client transitions home, the North West LHIN

recently conducted a time-limited pilot project to support high-risk geriatric clients for two weeks

following discharge from rehabilitation by the same team of OT, PT and rehabilitation assistants. The

model proved to be an effective way to support discharging high risk geriatric clients as soon as possible

to their home and eliminated the issues with transitions and communication identified above. Especially

for time-limited OT services, it is client centred and efficient to have the same professional follow the

client home to ensure the home environment meets the needs of the client. The same is true for short-term

PT services. This model already occurs in some regional communities since the hospital and the

contracted CCAC provider employ the same OT and PT. Eliminating an additional healthcare provider

team involved with the client and the associated assessments and documentation for such a short period of

time gains efficiencies and minimizes client care transitions. It is recommended this program model be

further investigated by the North West LHIN to track specific outcomes to determine cost effectiveness

and reduced ER visits.

In addition, a follow-up phone call to CCC and Rehabilitation discharged clients was implemented by

SJH. Clients very much appreciated the follow-up phone call. The major concern expressed was related to

PSW’s not arriving to provide care. In follow-up with CCAC, clients were given information to contact

the CCAC directly.

Hospital-based Outpatient Programs

Within the North West LHIN, the majority of outpatient services are delivered in hospital-based

programs. In addition, as indicated in Table 27, hospital-based outpatient departments are the only

publicly-funded PT services available in all communities except Thunder Bay, and the only available PT

services in all communities except Thunder Bay, Dryden, Kenora, and Fort Frances where private PT

clinics are also available. As outlined in the mapping tool exercise, hospital-based outpatient PT services

are available at each of the hospitals across the North West LHIN providing both progression and

maintenance levels of community rehabilitation. The ability to identify current and future needs for

outpatient services is difficult and an area where the RCA is working to further inform each LHIN and the

province.

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Hospital-based Outpatient Utilization

As noted above, within most LHHs, hospital-based programs represent the only available outpatient

rehabilitation option, as most communities are too small to support private clinics. Table 28 indicates the

number of patients and visits served in the North West LHIN.


All hospitals in the North West LHIN have dedicated resources for outpatient PT, with varying wait time

lengths, but very few have outpatient OT and SLP services. The availability of local PT services was

identified as a system strength. The lack of OT and SLP was clearly identified as a gap during stakeholder

consultation with both healthcare providers and clients and families. In particular, services for cognitive

deficits, return to driving, and speech and language deficits were identified. Innovative solutions to

address the issues noted include sharing an OT resource with the Dryden Family Health Team to provide

more community-based OT services for driving, community reintegration and cognition; and using

Personal Computer Virtual Conferencing (PCVC) connections to address the gap in adult SLP services.

Facilities that do offer these services have variable wait times to access these services. As such, it is

evident that the current services are insufficient but the determination of exact need is difficult at this

time. It is recommended that each LHH has the local services of an OT to serve both inpatient and

outpatient levels of care and facilitate transitions home.

Specialized Programs

Supporting CCAC and hospital-based outpatient services are several specialized programs. These

programs are designed to meet the needs of specific populations who require ongoing therapy not

otherwise available within a community. In general, the specialized programs in the North West LHIN

provide direct therapy locally in Thunder Bay and some provide access regionally. Others provide

informal consultation and subject matter expertise as requested. Many of the specialized programs

incorporate chronic disease self-management into client treatment plans. Presently, there is no formal

knowledge exchange system for all specialized programs. It is recommended regional access to

specialized services be made available to encourage the opportunity for clients to receive outpatient

services as close to home as possible, or within their home environment.

Currently, specialized outpatient programs are primarily available in Thunder Bay, with the majority of

services being provided through SJH, TBRHSC, and CCAC services. Among the specialized programs

are:

• Rheumatic Disease Program*

• Neurology Services*

• Amputee Clinic*

• Moving On After Stroke (MOST)*

• Pulmonary Rehabilitation, COPD, CHF Program

• Cardiac Rehabilitation*

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• VON Falls Prevention Program*

• Lymphedema Management*

• Regional Joint Assessment Centre (RJAC)*

• Intra-spinal Assessment and Education Centre (ISAEC)*

• Regional Wound Care Program*

*Denotes programs that provide a regional service through consultation, regional block admissions, or

technology-based regional service delivery platforms

Regional access to specialized programs currently ranges from consultation, when requested, to regularly

schedule telemedicine-connected exercise and education programs. Many specialized programs are able

to meet the needs of regional and remote clients; however, current outpatient service delivery models are

often insufficient to provide adequate specialized care outside the City of Thunder Bay. This results in

limiting access to only those clients who are able to attend programming outside their home community.


During regional stakeholder engagement, both strengths and gaps were noted in particular for the

following programs: Cardiac Rehabilitation/Healthy Lifestyles, Chronic Pain, Rheumatic Diseases, and

Neurology Services. The programs are noted to be specialized, client-centred, well-resourced, and

evidence-based; however regional access is limited due to wait lists, accommodations, and transportation.

The former Cardiac Rehabilitation Program, now called Healthy Lifestyles, is a well-established program

throughout the North West LHIN, at multiple LHHs. The program uses a central referral process with

physical assessment and exercise prescription completed at the TBRHSC site and local provision of

exercise and monitoring. The program supports regional service providers with initial training and

ongoing access to the coordinator for any questions or concerns. In addition, participants of the program

are able to access the monthly education session using videoconference platform. The program has a wait

list and some challenges accessing timely support with recent program staffing changes. To compensate,

some larger regional IDNs have continued to provide the program locally without any support from the

Healthy Lifestyles program. The program recently expanded to meet this identified gap and increased

opportunities for people with other diagnoses such as stroke and diabetes, to participate in ongoing

exercise and chronic disease self-management. This model of care provides a good opportunity to

leverage support for a variety of clients with chronic diseases throughout the North West LHIN.

The Chronic Pain program has adapted programming intensity and the overall length of the program;

however, continues to have challenges providing regional service. The program identifies it is difficult to

establish connections for ongoing local programming, with high staff turnover. The need for this program

is evident throughout the region and many LHH providers feel as though the referrals to this program

“fall into a black hole”. Recent increase in funding is hoped to address this gap.

The Rheumatic Diseases program is another well-respected program. St. Joseph’s Care Group

successfully delivered the Arthritis Care Network project using the Hub and Spoke model 12 years ago.

Ongoing tele-rheumatology services conducted by the rheumatologist with local rehabilitation support,

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and regular polyarthritis education workshops conducted by the Rheumatic Diseases team are examples

of sustainable initiatives developed from this project.

The Rheumatic Diseases Program continues to develop alternative models of care to meet the needs of the

ongoing need and recent reduction of local rheumatologists. The regional stakeholders noted this program

“works well for patients that get in!” Service providers at the LHH level appreciate the specialized

training provided to support the delivery of the program assessments using videoconferencing technology

but note ongoing “refreshers” of the polyarthritis workshops are beneficial and currently needed. They

also noted local physicians have recently been accessing visiting specialists programs and telehealth to

access rheumatologists throughout the province. Physiotherapists and OTs are appropriately skilled to

support these assessments; however, this has impacted their service delivery for other programming. This

is also an opportunity for coordination with the specialized service in Thunder Bay through integrated

triaging processes. Clients could then access specialized physician and support services in order of

priority.

The Neurology Day program is another program highlighted to fill a gap regionally due to challenges in

transportation and accommodation. Some clients are able to stay with family in Thunder Bay or access

accommodations and their experience with the program is very positive as noted by this family member:

“Without the physiotherapy that Dad received at SJG, Neurology Day and continues to

receive in Kenora, he wouldn’t have the quality of life that he does and the movement and

progress he has continued to make. We appreciated the option to continue in Neuro Day at a

more frequent intensity than was available in our own community.”

The Stroke Best Practice Guidelines indicate community-based therapy should be delivered at an intensity

of two to three times weekly for eight to twelve weeks following discharge from acute care or inpatient

rehabilitation. This is currently only available in the Neurology Day program in Thunder Bay. The

Ontario Stroke Network notes “patients living within 30 minutes’ drive were identified as outpatient

candidates and patients living beyond were identified as community-based rehab.” Accessibility to

community services following stroke should be less than 60 minutes from home. The Northwestern

Ontario Regional Stroke program is investigating a geo-mapping project to identify the 30-minute, 60-

minute, and 120-minute radius of each LHH in the North West LHIN. This will assist in identifying

where services are required throughout the expansive North West LHIN.

These three programs have made use of local, funded accommodations whenever possible, such as

Wequedong Lodge for Aboriginal clients and PR Cook bedsitter apartments funded by the North West

LHIN until December 2016. To access transportation, clients are encouraged to use the provincial travel

grant funding program and NIHB. However, there continues to be ongoing challenges with consistent

access to NIHB funding for medical transportation for rehabilitation.

Another identified gap is the lack of community-based respiratory therapy outside the pulmonary

rehabilitation program and asthma clinic in the City of Thunder Bay. Specifically there is an identified

gap to support clients with long-term palliative care and ventilation needs such as Amyotrophic Lateral

Sclerosis in the community.

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Models continue to be developed and programs expanded to work with regional service providers and

incorporate regional treatment and triage platforms, throughout the North West LHIN.

Community Physiotherapy Clinics

The primary rehabilitative care discipline provided in an outpatient setting is PT. The role of community-

based PT clinics has traditionally been divided between private care providers and publicly-funded PT

services. Private providers typically serve clients who have the financial ability to pay or access to

insurance coverage (extended health benefits, accident, or workplace injury-related). Publicly-funded PT

services are typically based within hospital settings or provided in-home through CCAC services.

Recently, the provision of publicly-funded PT services was reviewed and changes were made in August,

2013. A lack of access to community PT services was acknowledged across Ontario. The review

identified Designated Physiotherapy Clinics (DPC), introduced to increase access to publicly-funded PT

services, were primarily serving the Greater Toronto Area. As a result of this finding, clinic-based PT

services were expanded to include some publicly-funded services. These services were established to

ensure adequate access to PT services for underserviced populations in cities across the province. Within

NWO, eight clinics were allocated funding to provide a defined number of episodes of care (EOC) to

identified client populations. These allocations were distributed between hospital-based programs and

private clinic settings throughout the region, with the City of Thunder Bay clinics being funded by and

reporting directly to the MOH, and the regional programs accountable to the North West LHIN.

Table 33. Designated Physiotherapy Clinic Episode of Care Allocations for NWO

Community Physiotherapy Clinic City Allotted

EOC

Fairway Physiotherapy Clinic Thunder Bay 706

Closing the Gap Thunder Bay 707

Lake of the Woods District Hospital Kenora 342

Dryden Regional Hospital Dryden 183

Red Lake Margaret Cochenour Memorial Hospital Red Lake 48

Atikokan General Hospital Atikokan 200

Wilson Memorial Hospital Marathon 308

Meno Ya Win Health Centre Sioux Lookout 124

Total 2,618

In order to qualify for publicly-funded PT services through the CPCs, clients must have a valid Ontario

health card, a referral from their physician or NP, and meet one of the following criteria:

• Age 65 or older.

• Age 19 or younger.

• Any age after overnight hospitalization for a condition which requires PT (and for which they are

not otherwise eligible through other publicly-funded programs).

• A recipient of Ontario Works or Ontario Disability Support Program (with or without a valid

health card).

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Services provided within the designated CPC include assessment, diagnosis, and treatment; with the goal

of improving or developing physical function; and promoting mobility when function and/or mobility has

been lost or impaired as a result of a debilitating event or disease, pain, injury or surgical procedure.

Discharge is dependent upon client achievement of therapeutic objectives identified in their treatment

plan; or when equivalent gains could be achieved through an exercise, falls prevention, activation, or

similar program; or when no further gains are likely to result from ongoing PT. Current evaluation of

these CPCs indicates services are utilized in all identified programs. Presently, all clinics but one

provided either a measure of EOC or volume of clients seen within 2014/2015 or 2015/2016 with all

clinics reporting at or near their allotted volumes. Consistent measures of EOC volumes by all community

clinics will enable ongoing comparison and adjustment of service funding according to regional demand.

It is an expectation clients will be treated according to recommended guidelines and therapeutic goals;

however, through this review it has become evident differences exist with respect to treatment philosophy

among designated clinics. Due to the limited funding available for each EOC, some clinics provide

primarily consultative services to clients, while others provide more direct “hands on” treatment

approaches. It is recommended a standardized treatment approach, and clearer expectations regarding the

intended use of the funding be developed and monitored. Participation in the RCA minimum data set will

help to ensure the appropriate levels of care and EOC allotment are in place for each clinic.

In addition, provincially there is variation whether CPCs provide PT services to clients following post-

joint replacement surgeries at CPCs. The current Primary Joint Replacement QBP clinical handbook

indicates these clients should not be seen under the EOC payment model in CPCs as funding is provided

within the QBP framework; however, these handbooks are being reviewed provincially and parameters

need to be confirmed and further discussed as regional rehabilitation models are implemented.


Ongoing evaluation of the PT needs within communities that do not currently have allocated CPC funding

is required. An initial review of outpatient PT volumes in these communities is available from the RCA

mapping tools for community levels of care. According to these surveys, among the communities without

a designated PT clinic, Fort Frances reported the greatest volume of clients seen in their outpatient PT

clinic. A more detailed evaluation of the client demographics within outpatient PT clinics and monitoring

of the CPCs to ensure there is an increase in outpatient service volumes will help to inform ongoing

decisions regarding the need for further designated CPCs across the North West LHIN.

In addition to the new CPCs, there are three other PT clinics providing publicly-funded PT services

within the North West LHIN. Two clinics in Thunder Bay, Victoriaville Physiotherapy Centre and

Thunder Bay Physiotherapy Centre, provide services with special funding directly from the Ministry of

Health and Long-Term Care and the Mary Berglund Community Health Centre in Ignace provides PT

services through their Ministry of Health-funded global budget. Although these clinics do not receive

funding from the North West LHIN, their services are similar to those offered at the CPCs. In Ignace

however, the PT services provided include cardio-respiratory, neurological, and wound management in

addition to the typical orthopaedic caseload. The clinic uses an interprofessional team model with nurses,

physicians, and PTs to ensure appropriate care for clients. At present, a PT is contracted from Thunder

Bay and provides direct services in the clinic one day a week and uses OTN videoconference services a

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second day a week to do initial assessments and initiate treatment as appropriate, maximizing the use of

the time in person. In addition, the Mary Berglund clinic offers cardiac rehabilitation using

videoconference access for the twice-weekly exercise program and the monthly education component.

Joint assessments with rheumatology specialized clinics are also provided locally using videoconference

allowing the clients to remain in their home community. There are currently no PT services provided at

the other Community Health Centre sites in Thunder Bay, Armstrong, and Longlac. There is opportunity

to provide PT services through Family Health Teams and the NorWest Community Health Centre similar

to the Mary Berglund Community Health Centre.

Community Exercise Programs

Rehabilitation services include the entire continuum of care from inpatient to outpatient services to home

care to ongoing community exercise. As described earlier, only exercise programs requiring service

provision from a regulated healthcare provider are included in the scope of this report. For the North West

LHIN, this includes the Community Exercise and Falls Prevention Classes delivered by Dryden Regional

Social Services in Dryden and throughout NWO (Thunder Bay, Atikokan, Emo, Fort Frances, Ignace,

Kenora, Sioux Lookout, Marathon, Manitouwadge, and Nipigon, Rainy River, Red Lake, Red Rock,

Schreiber, Terrace Bay) by VON. In addition to the exercise programs mentioned, SJH also delivers

disease-specific exercise classes for people in the City of Thunder Bay in the community, in partnership

with the Canada Games Complex and the 55+ Centre. Trained fitness instructors, not healthcare

professionals, deliver these classes and participants are all assessed and monitored by a PT. The

partnership also outlines the ability for the instructors to consult with the PT at any time. This model has

potential for ongoing exercise programming throughout NWO, in particular the remote communities in

the Far North.

Strengths, Gaps, and Limitations

Health service providers identified the availability of ongoing, supervised exercise programs as a strength

of the healthcare system within NWO; however, they suggested better marketing of the programs, better

integration with rehabilitation services at the hospitals and any private clinics, and better availability to

the remote, northern communities. In Dryden, PTs working in-home assist clients to transition to these

programs as part of their care.

Summary

Similar to inpatient rehabilitative care, outpatient rehabilitation provided within the community and

outpatient facilities in NWO will be standardized according to provincial norms. At present, outpatient

and community-based rehabilitative care programs in the North West LHIN are fully aligned with

provincial definitions.

Currently, there are several outpatient programs providing rehabilitative services in the region. These

programs provide examples of regional group-based service delivery, including OTN opportunities,

allowing clients to access specialized education and exercises within their home community, and remote

access to assessment and triage. Learning from the existing strategies, all specialized rehabilitation

programs should evaluate their service delivery for opportunities to provide regional assessment, triage,

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and treatment services. In addition, it would be beneficial to integrate access to the visiting specialist

programs throughout the North West LHIN.

As a result of the many avenues to access outpatient services, there are frequent difficulties in

determining the most appropriate service for clients. Further complicating the referral process for

outpatient services is the requirement of a physician referral to access many programs. Wait times for

non-urgent appointments with primary care physicians range from weeks to months and thus the

requirement for a physician referral to access publicly-funded rehabilitation services is an added delay.

The combination of these factors has led to a system in which clients are often referred to multiple

programs, or inappropriate services. To help alleviate some of the difficulty surrounding eligibility

criteria for PT services, a detailed referral flow chart was developed by all stakeholders throughout the

North West LHIN led by SJH. This chart was designed to help guide clients to the most appropriate

service, while at the same time increasing awareness of the available services across the region (Appendix

O). It was also intended as a tool for primary care providers to assist them in referring directly to the most

appropriate service provider within the North West LHIN and was made available to outpatient service

providers for distribution to primary care referring partners. The dissemination and reinforcement of these

tools should be part of the implementation plan of the regional rehabilitation program. It is also

recommended the need for a physician referral should be eliminated whenever possible, especially when

clients are transitioning between levels of care for the same issue.

In order to integrate services and improve access across the region and the care continuum, it is

imperative all services are aligned, from regional providers to LHH providers, and inpatient teams,

specialized services, and outpatient services. This connection and ongoing communication will ensure all

clients are able to easily access regional specialized programs and local rehabilitation services in their

home community or as close to home as possible. In addition, this connection will ensure as client

demographics and available programs change, clients will continue to receive the care they require in a

timely, coordinated manner.

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Health Human Resources

The provision of rehabilitative care services is largely dependent on regulated healthcare providers within

each facility. Direct service providers are a significant strength within rehabilitative care in NWO.

Through the capacity planning process, it is clear client needs are placed at the highest priority within

each care facility. Further, the clinicians providing care have demonstrated the tenacity to work with

limited resources, ongoing staffing challenges and, at times, minimal supports.

Throughout these challenges, the strength of individual care providers and collective creativity in care

provision has developed. This creativity is a significant strength and, with some encouragement, can be

directed into a collective rehabilitative care system to serve the entire region. Currently, collaboration

occurs on a localized scale within rehabilitation networks formed in the District of Thunder Bay and west

of Thunder Bay including District of Kenora, District of Rainy River, and Northern IDNs. These groups

meet on a quarterly basis to support care provision, education needs, and collaborate as providers. Further

coordination of these groups into a regular LHIN-wide collaboration will serve to strengthen the

connections and knowledge sharing across our entire region.

One of the primary challenges in providing care within NWO is the ability to maintain a steady

compliment of allied healthcare providers within each facility. The HSPs throughout the North West

LHIN have partnerships with academic rehabilitation facilities, in particular McMaster University and the

Northern Ontario School of Medicine (NOSM), to facilitate clinical teaching for students. This is a source

of recruitment as well as a retention strategy for rehabilitation professionals. The Northern Studies Stream

academic portion of McMaster University for both OT and PT was recently discontinued. This eight-

week academic block followed by a six-week clinical placement program was highlighted as a key

recruitment and retention strategy for rehabilitation staff throughout NWO. The program was

discontinued in a cost-savings measure, as it was determined recruitment is no longer an issue in the

North. The loss of this program was reported as a concern for future recruitment and retention during

engagement sessions.

Due to the low volumes in smaller facilities, there is not always a need for full time professionals.

Healthcare providers in NWO are often working in multiple locations or across a variety of services,

which further challenges the already difficult process of recruiting and retaining healthcare professionals

to remote and northern regions. A specific examination of OT, PT, and SLP availability is necessary in

the review of rehabilitative care. The current allotment of allied healthcare providers is provided in

Appendix P. This information is based on a current snapshot and frequently fluctuates. In the region,

allied health staff is generally shared between inpatient and outpatient programs and will at times work

within Family Health Teams, and/or provide care through the CCAC, in order to maintain a full time

equivalent (FTE) position. The CCAC contracted rehabilitative services may have to travel to a number of

communities in order to provide service and provide service across age groups, from children to adults.

The low population density and large geography make it difficult for clients to access care and for

providers to meet the needs of clients in the region.

One unintentional benefit of service providers working across the continuum of care is the continuity of

care for clients. The inpatient PT may also be the outpatient as well as the CCAC contracted provider.

Therapists noted client transitions were smooth, coordinated, and efficient as client rapport is already

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established and access to information and communication is easily facilitated. There are occasions when a

sole service provider negatively influences client provider choice while accessing care. However, the

same therapist is most often advantageous for both clients and healthcare providers, especially if it allows

the service providers to pool resources and offer a full-time position.

Staffing considerations are important when evaluating the opportunity to provide rehabilitative care. All

four definitions of rehabilitative levels of care require some degree of interprofessional care, but the

rehabilitation level requires a coordinated, interprofessional rehabilitation plan of care with a team which

should include: dietitian, discharge planner, nurse, OT, pharmacist, PT, physiatrist and/or geriatrician,

social worker, and SLP. The gap in OTs in the District of Thunder Bay and lack of SLPs throughout the

North West impacts the provision of rehabilitation. The recent addition of funding for Assess and Restore

programming by the North West LHIN has supported positive increases in service provision such as an

OT in Kenora, a SLP in Dryden, and a Kinesiologist in Sioux Lookout. Best practice guidelines for Spinal

Cord Injury and Acquired Brain Injury and QBP guidelines for stroke and hip fracture specify the needs

for adequate interprofessional staffing and sufficient client volumes in order to provide the prescribed

level of care. In order to maintain adequate staffing to provide the required levels of rehabilitative care,

consideration must be given to providing full-time, permanent positions to attract the required

rehabilitative professionals.

Where it is virtually impossible to recruit regulated health professional rehabilitative staff, it is worth

exploring creative use of rehabilitation assistants or extended role personal support workers to provide a

minimum level of care under the guidance of the regulated health professional. Professional Regulator

College standards need to be carefully considered when exploring these models of care; appropriate

training, supervision and maintenance of skills needs to be implemented; and appropriate funding is

required to match the increase in service provision for both volume and skill. It is important an integrated

rehabilitation system across the region is nimble enough to provide the appropriate care for the client in

times of health human resource shortages.

Special Consideration for Northern and Remote Issues in North West LHIN

As noted in the demographics and population health section on page 21, a large geographical area, small

population numbers, and poor social determinants of health when compared with the rest of the province

of Ontario, challenge the North West LHIN. Furthermore, the North West LHIN services 32 Northern,

remote Aboriginal communities with the same challenges, only amplified. These communities are

accessible only by air. The communities vary in size from less than 100 people to approximately 3,000

people. Issues related to access, intergenerational trauma, and racism further challenge the social

determinants of health. To complicate matters further, healthcare and related rehabilitation care in these

communities is funded by multiple agencies including Health Canada, NIHB, and OHIP, which must be

navigated. While each community is unique, there are some commonalities.

The federal government is the primary provider of health services on reserves. The Home and Community

Care Program (HCCP) is funded by the First Nations and Inuit Health Branch (FNIHB) of Health Canada

to assist people who have chronic and acute illnesses or disease to receive the care they need in their

home or community. The amount of funding allocated to each community through Health Canada’s

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Primary Care or HCCP budgets is population-dependent based on 1997 Indigenous and Northern Affairs

Canada population statistics. Rehabilitation services are not funded as an essential service under the

HCCP and therefore are only provided if budget and staff capacity allow, making it difficult for small

communities to provide most of the required rehabilitation services. There are some communities within

Ontario who have partnered within their treaty organizations or tribal councils to share resources and are

therefore able to provide more services. An example of this is Dilico, an in-home service provider for

nine communities. With amalgamated funding, Dilico is able to provide a nurse to multiple communities,

contract PT, OT and SLP services, and are even piloting a part-time care coordinator in the TBRHSC to

assist with discharges from this facility. The combination of multiple funding sources and different

providers make it difficult to coordinate care for the rest of the Aboriginal communities in the North

West.

Throughout most of the far north, access to rehabilitation is relatively non-existent. There are currently

only three PTs (no OTs or SLPs) servicing only 10 of the 32 communities, every two to three months. To

be effective and provide service for both in-home and outpatients, teaching family, clients, and existing

staff to carry out programs and providing general exercises throughout the community is required.

Unfortunately, the inconsistent presence of rehabilitation service providers presents the same challenges

to care transitions and communication outlined in the inpatient section of this report.

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Communication between health service providers has been identified as a major issue impacting the

continuity of care for all residents of the North West LHIN, but is exemplified in the remote Aboriginal

communities. There is often a gap in communication when an Aboriginal community member is

discharged from a hospital to return to their home on reserve. One stakeholder noted: “when our clients

are discharged from the hospital, the tie is severed.” Another noted: “There is an information void!” They

are often not informed when one of their community members is set to return home from the hospital.

These communities have no access to the common electronic medical record. There is no clear transition

or formal hand-off from the hospital to the providers on-reserve as there is often no appropriate follow-up

provider with which to connect. To complicate matters further, each community is unique in their

relationship between the nursing station and the HCCP. Rehabilitation providers at the hospitals often do

not know who the appropriate contact is for each Aboriginal community regarding making arrangements

for home care and any possible ongoing rehabilitation once the individual is discharged. In some

communities, there may be multiple service providers who each play a role in coordinating home and

community care. There is also a concern for respecting the individual’s privacy and maintaining

confidentiality. Home and Community Care Program staff and workers in the Band’s Heath Department

are often inappropriately not included in the Circle of Care communication. There is currently a “patient

portal” project in Thunder Bay for clients identified with high healthcare needs. This portal provides a

secure system for providers and the client to upload and have “read only” access to information such as

discharge plans, lab results, etc. This portal system has the potential to improve communication and client

care in Northern and remote communities. Communication with all appropriate parties takes time, but is

essential to have accurate, complete information.

It is current practice to transfer clients to Meno Ya Win Health Centre in Sioux Lookout for a short time

prior to final discharge home. Meno Ya Win Health Centre is unique in that it provides medical services

to approximately 32 Northern Aboriginal communities. Meno Ya Win has a hostel, traditional healing

room, and available interpreters, in addition to traditional hospital services which are helpful to support

more complicated discharges. When discharging to northern communities, it can be challenging to

coordinate services and equipment as each community operates independently and NW CCAC does not

provide service on First Nations. Follow up PT can be arranged in some communities but not all, and OT

follow up services are not available. Clients who no longer require acute hospital services are transferred

to the hostel attached the hospital; this way, the client can continue with the Assess and Restore

interventions twice a day and maximize their gains prior to returning home. A social worker coordinating

discharge planning is aware of the community services available.

Issues with accessing equipment for clients and having clients and families access rehabilitation at the

appropriate location challenge rehabilitation staff. Consultation with stakeholders from various service

providers, funding agencies, tribal councils, and Aboriginal liaisons at the North West LHIN confirmed

these identified areas of concern and ongoing inconsistent interpretation of legislation. Examples include

the NIHB medical travel and medical equipment policies; and the lack of provision of services by CCAC

to Aboriginal communities, both rural and remote.

Currently, Assembly of First Nations and FNIHB are jointly reviewing NIHB nationally. Of relevance are

the medical transportation benefit and medical supplies and equipment benefit policies. Input from

rehabilitation agencies across the North West LHIN have been submitted (including submissions from

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SJH) expressing concern and recommendations regarding access to services. The concerns outlined in the

submission were also highlighted during this stakeholder engagement session. As noted earlier, there are

often no, and at best very limited, local rehabilitation services in most of the Aboriginal communities in

the Northern IDN. Access to any of the aforementioned publicly-funded programs at the hospital or CPCs

require transportation by plane and local accommodations. At present, most outpatient appointments for

rehabilitation do not qualify for NIHB travel and accommodation funding due to a lack of OHIP billing

code. As stated, most outpatient rehabilitation services and specialized regional services are provided

within a hospital global budget. Without funding for travel and accommodation, these services are not

accessible to the community members due to the sheer cost of travel. While it is acknowledged there is a

process in place for clients to make appeals regarding NIHB decision, this process results in further

delays in accessing service and the inefficient use of scarce health human resources to navigate the

system. Medical Transportation is essential to access rehabilitation services for most Aboriginal people in

the North West LHIN.

In addition to access for the client, the Medical Transportation Benefit also provides transportation and

accommodation for family members as medical escorts. Healthcare providers rely on informal family

caregivers to assist with rehabilitation recommendations throughout the continuum of care at home. It is

essential these family members be recognized as a part of the rehabilitation team, with the client and

healthcare providers. Their involvement also helps improve communication.

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The second benefit under review is the Medical Equipment and Supplies Benefit. Equipment needs are

also highlighted as a particular challenge. Other LHHs in the North West LHIN noted difficulties with

vendors delivering equipment twice a week; however, for these northern Aboriginal communities there is

no availability of rental equipment at all. Home and Community Care programs are required to provide

the necessary short-term equipment, but the budget is very limited. Healthcare providers (when available)

complete prescriptions for personal equipment, but the approval process for the necessary equipment is

time-consuming. Provincial and personal funding programs are accessed first, often with a four to six

week approval process, before being submitted to NIHB for approval, which involves another four to six-

week approval process in many cases. In addition, NIHB equipment prescriptions require extensive

personal information and medical justification, which is not congruent with current privacy legislation.

Furthermore, the Northern and remote environment requires the appropriate equipment with more regular

maintenance (which is unavailable) or replacement sooner. Recommendations to streamline the

equipment approval process have been outlined in the review submission.

Over recent years, there have been funded pilot projects to improve access to rehabilitation services in

Aboriginal communities. Initiatives such as the Moving on After Stroke (MOST) program connection

with Sandy Lake First Nation, the Sandy Lake Community-based Primary Stroke Prevention Program,

and the Rheumatic Diseases visiting therapist program in Fort Hope are examples of outpatient services

with extended access to remote communities in a limited capacity. While these programs have

demonstrated success in partnering with a specific community, several initiatives to increase the

availability of local service provision within remote northern communities have failed to have long-term

sustainability.

Trials to provide tele-rehabilitation consultations were successful from the telehealth studios in the local

nursing station but not without challenges. Challenges included the bandwidth required and availability

for some communities, the availability of consistent and reliable staff to manage the program as well as

support the client appointments, ongoing training requirements due to staff turnover, and in some

communities, access to operational equipment. Trials with an in-home camera were more challenging due

to the complicated technology and extra security measures required. Barring these issues, there is a huge

potential to provide telemedicine follow-up appointments with rehabilitation staff after hospital

admissions, visits to outpatient clinics, or after local therapist visits, to improve access to rehabilitative

care.

The need for ongoing communication and development of relationships with each of the unique

communities, although essential, takes time. Everyone has a right to culturally safe care in their own

language and access to their traditional healing practices. Regardless of improvements in the processes

around rehabilitative care provision, there is a lack of access to these services for the Aboriginal

population in the North West LHIN. The provision of rehabilitation services is an essential part of the

healthcare continuum and this gap needs to be addressed.

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Desired Future State

The vision for NWO is to create a system of care which will serve all individuals who could benefit from

rehabilitative care. The system will respond to the needs of the individual and their family and caregivers

as well. A full continuum, of care will be available from inpatient rehabilitation to outpatient

rehabilitation and community reintegration all within a chronic disease management framework. All

individuals, regardless of their care setting, will receive care that is client-centred, culturally safe, focused

on enhancing quality of life, delivered by an interdisciplinary team, and close to home. Individual and

family needs will be identified early to engage them as partners in all care planning and decision-making.

A model for rehabilitative care cannot be developed in isolation from the system as a whole. The desired

future state of rehabilitative care described here has been developed in alignment with the North West

LHIN Blueprint integrated health service delivery model and within existing resources. As noted earlier,

the province’s healthcare allocation model is primarily population-based. It is anticipated the North West

LHIN growth rate will remain below provincial averages and, as such, no funding increase is anticipated,

except for provincial initiatives, such as Palliative Care. The North West LHIN Blueprint recommends

identifying opportunities to meet increased demands for health services within existing resources. Within

an integrated model of care, healthcare providers across the region work together to organize services and

delivery of care.

Within NWO, delivery of services is organized across the following levels:

11. Fourteen Local Health Hubs (LHH) which provide services based on unique needs of their communities.

12. Five Integrated District Networks (IDNs) with District Health Campuses which provide specialist care to clients within the district.

13. Specialized regional programs that serve all of NWO.

Figure 3. North West LHIN Health Services Blueprint Integrated Services Delivery Model

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Each LHH, in conjunction with the Regional Rehabilitative Care Program, will arrange for the provision

of a coordinated continuum of rehabilitative care services. Specialized regional programs focus on high

cost, high complexity, and high impact services to ensure the provision of specialized care throughout the

North West LHIN. These programs may be delivered at the local level, or in a regional centre. Regional

programs are determined largely on the ability to deliver care based on best practices, including

provincially recognized QBPs. Figure 4 visualizes the structure of this integrated system.

Figure 4. North West LHIN Regional Rehabilitative Care Program Model – Integrated System of Care

The Hub and Spoke model of care is not new to healthcare and is typically implemented in rural and

remote areas where larger centres have more specialized and comprehensive services (the hub) than the

smaller, remote communities (spokes) where population, economies of scale, recruitment, and retention

do not support the same level of care. The model aims to formally integrate rehabilitation services across

the region by leveraging existing services and expertise from a hub centre to enhance and support existing

services in each spoke community. Northwestern Ontario fits the profile with a large area and many rural

and remote communities, and therefore would benefit from this model of rehabilitation service delivery.

Within the current state evaluation of rehabilitative care in NWO, the need was identified for an

integrated delivery model to increase coordination within and across all levels of care. The North West

LHIN is currently in the demonstration phase of implementing Integrated Health Care Organizations

(IHCO) who will provide end-to-end integrated services at the local level. Within rehabilitative care, this

will include inpatient, outpatient, and community rehabilitative care in addition to local chronic disease

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management. Each IHCO will be responsible for coordinating local services and ensuring appropriate

care provision is available within each LHH. Collaboration between specialized rehabilitative care

services and the described regional service delivery model will ensure client needs are met as close to

home as possible.

This model will promote improved access and better transitions in care by encouraging integration within

each level, and across all levels of care. The overall goal of an integrated system is to provide excellence

in care, built on a vision of improved access and flow, standardization, coordination, and the use of

evidence-based care to improve the client journey.

The following information provides an overview of the key elements included in the future state of

rehabilitative care in the North West LHIN. The future state model has been developed to build on the

existing strengths of the current system, and help to overcome the gaps in care delivery identified within

the current state analysis. Overall, the future-state model of rehabilitative care will align with the future

state of healthcare within the North West LHIN. This will include defining the rehabilitative care lead

organization, implementing regional rehabilitative care streams roles, specific focus on enabling

flexibility in local hospitals to meet care needs, establishing partnerships with the IHCO’s, identification

of regional programs, and improving regional access to all rehabilitative care services.

Regional Rehabilitative Care Lead Organization

Within the integrated health system model, leadership is critical for coordination and planning, over and

above of service delivery. Lead organizations require the necessary human and capital resources to

develop a sustainable system for rehabilitative care throughout the region, facilitating access to

specialized programs and services for the residents of the North West LHIN within the Chronic Disease

Management framework. In addition, the Regional Rehabilitative Care Lead is intended to provide

support to both clients and clinicians throughout the five IDN’s. The foundation for successful integration

of rehabilitative care will be largely dependent on collaboration and joint planning between the Regional

Rehabilitative Care Lead Organization, LHHs, and IHCOs. Formal structures to support communication

between these organizations will be required to ensure a seamless journey through the various stages of

rehabilitative care, ensuring each client has access to the right care, at the right time, and in the right

place.

The Regional Rehabilitative Care Lead Organization will:

• Be recognized as leaders in enabling evidence-based care throughout the North West LHIN.

• Be recognized in the LHIN and provincially as demonstrating innovation and leading practice.

• Be able to change and embrace new thinking and successfully fulfill the role of early adopters.

• Work with the North West LHIN to implement the recommendations of this plan.

• Work with the North West LHIN to implement the plan to align with provincially mandated

definitions of rehabilitative care.

• Ensure care is based on evidence and leading practice throughout the North West LHIN.

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• Support collaboration and capacity building at the HSP, LHH, IDN, and Regional levels.

• Provide advice and advocacy to the North West LHIN on identified local and regional service

gaps, strengths, and priorities.

• Demonstrate strong partnerships and involvement in healthcare education and research.

• Lead the development of a standardized, quality, and integrated approach to rehabilitative care

across the continuum of care for the North West LHIN.

• Monitor, evaluate, and report on system performance and client and caregiver outcomes.

• Have the demonstrated ability to establish effective partnerships with both LHIN funded and non-

LHIN funded providers.

• Have the capacity to deliver LHIN-wide mandates for standardization, quality, and integration

across the continuum of care.

Within the North West LHIN, a primary role of the Rehabilitative Care Lead will be to facilitate

information and knowledge sharing across all health disciplines, and to ensure a minimum level of service

is available for all clients regardless of human resource limitations. In order to provide this level of

support, the Rehabilitative Care Lead organization will identify interprofessional care teams for each of

the Care Streams (see page 99) that consist of rehabilitation professionals who will be available to provide

assessments and consultation with regional providers as required. In addition, each care stream will have

identified leaders, a consistent contact and knowledge exchange expert for clinicians throughout the

region. This role will also help to develop regional communication networks for clinicians. As noted in

the Health Human Resources Section, rehabilitation networks already exist within and between IDNs to

support care provision, education needs, and collaborate as providers. Further expansion of these groups

into regular LHIN-wide collaboration opportunities will serve to strengthen the connections and

knowledge sharing across our entire region.

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Figure 5. Regional Rehabilitative Care Program Proposed Governance Structure

The Regional Rehabilitation Program will be housed within a host agency as shown in Figure 5. The

work of the Regional Program will be guided by an Advisory Committee and will be accountable through

its host agency to the North West LHIN. Task Groups will be created to support the implementation of

specific recommendations in this plan.

The Regional Rehabilitation Program is structured with two objectives in mind:

14. Leading regional level initiatives that will result in a standardized, evidenced-based, integrated

approach to care across NWO.

15. Supporting work at the IDN, LHH, and HSP levels to implement best practices and delivers

standardized rehabilitative care programs and services to all populations across the North West LHIN.

Under the guidance of the Regional Program, community facilitators will be identified at the LHH or IDN

level to lead the development of rehabilitative care in every LHH. The Rehabilitative Care Lead

organization, Care Stream Leads, and community facilitators will provide leadership to implement

recommendations from the Regional Program at the LHH level. With the support of the Regional

Rehabilitative Lead organization, the group will use Continuous Quality Improvement methodology to

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plan, implement, and evaluate initiatives to address specific gaps in their communities and then spread the

initiatives across the North West LHIN.

It is essential the Rehabilitative Care Lead organization help to facilitate access to rehabilitative care

resources and facilitate the future development of regional resources as required. Due to the ever-

changing state of rehabilitative care and availability of services in the region, it is essential the

Rehabilitative Care Lead organization remain aware of changes in the state of rehabilitation across the

region. This organization will additionally act as an advocate for rehabilitative care in the North West

LHIN among provincial stakeholders and be active in the RCA to ensure the needs of NWO residents are

being met.

Care Streams

As outlined above, examination of the current rehabilitative care system in NWO has indicated the need

for a formalized, integrated, and coordinated system to support specialized care across the region between

the three levels of care. This type of system will provide support to local healthcare providers and clients,

thus enabling clients to receive specialized care as close to home as possible. Due to the large geographic

areas, distances between service locations, and scarcity of resources, a single therapist is often responsible

for all clients requiring care within their community. These healthcare providers function as generalists,

so the ability for clients to receive specialized care within their community is often limited. In order to

support care as close to home as possible, three regional care streams will be implemented within NWO.

These care streams will support best practices, QBP adherence, and availability of specialized

rehabilitation for all clients. In addition, the care streams will provide opportunities for interprofessional

care teams consisting of rehabilitation professionals with detailed knowledge of diagnosis-specific

resources available within the region to provide assessments, triage, and consultation with regional

providers as required. Based on RCA bedded levels of rehabilitative care definitions, existing care

pathways, and client care needs, the following primary care streams will meet the specialized care needs

of NWO:

• Geriatric Assessment and Rehabilitative Care.

• Specialized Rehabilitation (Neurological, Stroke; Orthopaedic and Musculoskeletal) Services

Stream.

• Medically Complex Services (Wound, Lymphedema, Pulmonary, and Chronic Disease).

These care streams will maximize current high priority areas of rehabilitative care and available local

specializations. See Appendices Q-T for details. While clients may present with multiple medical

conditions, it is anticipated each client requiring ongoing rehabilitative care will align with one of these

streams for their primary condition.

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The identified care streams will leverage existing knowledge within NWO and will be linked directly to

the Rehabilitative Care Lead organization in order to ensure ongoing access to rehabilitative care from

anywhere in the region. Each stream will serve the following primary functions:

• Identification and triaging of all rehabilitative care needs through the use of a single point of

access and updated care pathways to determine the most appropriate location and level of care required.

• Assessment of individual clients to determine rehabilitative care needs and the most appropriate

location and level of care required.

• System navigation to allow clients and families to access the most appropriate rehabilitative care

program regardless of their referral location for the entire care continuum.

• Access to specialized physician services including assessment and treatment in the most appropriate location including technology-based support and outreach.

• Provision of rehabilitative care interventions at appropriate intensity, duration, and mode, by

appropriate professional team, in appropriate location including technology-based support and outreach.

• Development of resources and provision of education to clients and clinicians in order to provide

specialized evidence based practice.

• Support to regional care providers for complex, specialized clients.

• Support transitions between care locations to ensure clients access the most appropriate services,

including a designated inpatient rehabilitation program if required and transitions to primary care,

home, or community programs.

• Development of partnerships locally and provincially to support evidence-based care, innovation, and research.

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Figure 6. Roles of Care Streams with an Integrated Regional Rehabilitative Program

Screening Assessment Intervention Transition Navigation

Identification of

Clients with

Rehabilitation

Needs

Primary Care

Providers

ER/ Hospitals

Community and

Regional Agencies

Rural and Remote

Communities

Central Intake

Triaging and

information

gathering by phone

Determine most

appropriate care

stream

Within care stream,

determine required

services and

availability in LHH

vs. IDN vs. regional

program

considering

inpatient vs.

outpatient and use

of telehealth

Determine those not

requiring service;

referrals back to

Primary Care or

onto other

community

programs

Basket of

Services

Group or individual

rehabilitation at

appropriate

intensity, duration,

by appropriate

professionals

Inpatient or

outpatient care

In-home rehab and

health support

(RPN/CCAC)

Appropriate location

with use of

technology as

appropriate

Provision of

education, supports,

and resources as

needed for ongoing

care needs to both

client/family and

rehabilitation care

providers at LHHs

Planning for

Care

The team works

with client/family to

review needs and

options along the

continuum of care

Reevaluate Level of

care (Inpatient,

Outpatient, and

Community) and

availability of

required services in

LHH vs. IDN or

Regional program

Ongoing support at

time of transitions

between locations

and levels of care

CCAC involvement

for home service

coordination as

required

Decision

Guidance

The team identifies

a main contact for

client and family

until services end

Clients and

caregivers can call

back to Central

Intake if they

require service if

service ends

Comprehensive

Assessment

Single service

rehabilitation

professional OR

Specialized team of

rehabilitation

professionals

including:

Geriatrician,

Psychiatrist,

physiatrist, PT, OT,

SLP, nurse, social

worker, pastoral

care, dietitian and/or

therapeutic

recreationist

Transition to

Home

Short-term follow

up by individual or

team service

CCAC in-home

rehab service if

required

Transition to

Primary Care

Primary care

provider to follow

If client does not

have a provider,

team to assist that

link

Specialist may

follow in the interim

Transition to

Community

Programs

Other community

programs (Falls

Prevention, Keep

Moving with

Stroke, Parkinson’s,

Day Centres,

Alzheimer’s

Society, etc.)

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The North West LHIN will work in collaboration with the Regional Rehabilitative Care Lead

organization to design and implement the regional interprofessional care stream teams. It is anticipated

initially, significant education and engagement with primary care and regional clinicians will be required

in order to develop a referral pathway for the care streams. The goal of such engagement and education

sessions will be to encourage direct access to rehabilitative care, preventing further decline and enhancing

individuals’ level of functioning, as identified in the Walker Report, without the need for clients to attend

an acute care facility or ER. Specifically, it is recommended clients who are not acutely ill be referred

directly from community and primary care providers to rehabilitative care to receive specialized

assessment and delivery of the optimal level of care (Figure 7). This will decrease the reliance on acute

care, community, and LHH providers to refer clients to specific programs; and eliminate the need for

physicians and referrers to know the specifics of all the programs. Engagement with front line

rehabilitation providers throughout the North West LHIN suggests primary care providers would be key

in identifying these clients. This model has the potential to prevent hospital admissions and may help

decrease the ALC to LTC rate in the North West.

Figure 7. Regional Care Stream Conceptual Model

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Figure 8. St. Joseph’s Hospital Care Stream Model

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When it is determined a client requires rehabilitative care, they will be referred to the most appropriate

care stream using a central intake or single point of access. A screening process will determine the

appropriate location and level of care for assessment and care planning. For specialized or complex

rehabilitation needs, clients would access an assessment by an interprofessional care stream team at St.

Joseph’s Hospital using specialized knowledge of their primary rehabilitative care area and a foundation

in Chronic Disease Self-Management. Given the client’s rehabilitation needs, goals, and home

community, the most appropriate level of care and program will be determined. Interprofessional care

within each stream will include access to a team including (as required): OT, PT, SLP, Social Worker

(SW), Dietitian, nursing, specialized physician/Nurse Practitioner (NP), and any other condition-specific

disciplines. Through the use of standardized assessments, communication tools, and care practices, each

team will be able to support client care across the continuum of rehabilitative care including inpatient,

outpatient, and community settings.

To support service delivery, the care streams will have a knowledge exchange strategy. This knowledge

exchange strategy will be supported by the Regional Rehabilitative Care Lead Organization and will

include the following: identified clinical and specialist physician leads, an accessible website, and an

annual retreat. The identified leaders will be a consistent contact and knowledge exchange expert for

clinicians throughout the region. Using the Rapid Access to Consultative Expertise (RACE) model,

clinicians throughout the North West LHIN will be able to connect via telephone for urgent questions and

consultations and use e-consultation for non-urgent questions and consultations. The care stream leads

will also have rapid access to professionals within the team such as physiatrists, rheumatologists, and

geriatricians, should the consultation require a more profession-specific focus. A model similar to this is

in place for the North West LHIN Regional Palliative Care Program, providing access to clinical expertise

on a 24/7 basis using SJH Palliative Care Unit as a resource. This model supports provincial and local

values including access, decision-making, clinical judgment, education, knowledge transfer, and practice

efficiencies, as well as alignment with the Triple Aim Principles of enhancing the care experience,

improving population health, and controlling per capita costs of healthcare.

A website is another platform for referrals (healthcare provider only portal) and information sharing

regarding best practices, program descriptions, community resources, contact information, and self-

management resources for clients, families, and healthcare providers. It is essential the website be

accessible in both English and French languages due to the demographics of our region. This will require

significant time and investment and therefore a phased in approach is recommended.

The final component of the knowledge exchange platform is an in-person annual retreat hosted by the

Rehabilitative Care Lead organization. This forum will build capacity and provide an opportunity for best

practice updates, case study discussion, clinical skills training, and practical advice about data collection,

assessment, and treatment updates for each of the care streams. The hands on education components of

this forum will be helpful in addressing the knowledge, skill, and rehabilitation culture gap for nurses

throughout the North West LHIN as identified during stakeholder engagement. An additional component

of this annual retreat should be clinical education, an opportunity to leverage existing partnerships with

NOSM and provide assistance with long-term planning recruitment and retention. Most importantly, the

retreat will provide an opportunity to network and connect with one another in person, which will

improve future communications required for effective client transitions and an integrated system.

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Within the broader scope of rehabilitative care, the care stream teams/leads will communicate with the

Regional Rehabilitative Care Lead organization and district IHCO’s and LHHs to continually monitor

available inpatient, outpatient, and community programs, and to establish regional programs to increase

access to evidence-based care via outreach as per the Regional Rehabilitative Care Program governance

structure.

It is expected the outcomes of the care stream model will be improved access to the most appropriate

rehabilitative care program for each client as close to home as possible, improved transitions for each

client with improved communication among the care team, increased access to best practice and QBP

recommendations for all clients and clinicians, and a clear care path for every client who requires

rehabilitation in the North West LHIN.

Flexible Inpatient Beds at the DHC and LHH Levels

In order to meet the continually changing needs of regional facilities, the future state model of

rehabilitative care will be flexible. It is essential the care system within the DHC and LHH levels be

designed to allow flexibility of care for each individual client. As identified in the Walker Report, instead

of aligning specific levels of care to pre-determined beds, facilities will adapt their resources to meet the

needs of the population. Rehabilitative levels of care will be determined on an individual basis and the

appropriate level of rehabilitative care will be provided to the client, regardless of the “bed” definition.

At present, the majority of rehabilitative care provided outside of the City of Thunder Bay occurs within

designated acute care beds; beds allotted for CCC are being utilized for clients designated ALC to LTC.

Care providers throughout NWO indicate the appropriate level of rehabilitative care is being provided,

regardless of the bed definition. Tables 4 and 16 describe the current estimated bed days required for each

of the levels of inpatient rehabilitative levels of care. Interestingly, many of the estimates appropriately

match the current number of designated CCC beds.

Aligning with this approach, the proposed future system supports the independent assessment of each

individual requiring inpatient rehabilitative care. Clients will be identified as being “rehabilitative” once

they become medically stable and are no longer accessing care for acute medical management. At this

time, their medical, nursing, and therapeutic care needs will be evaluated and the level of care determined

according to the standardized bedded levels of care definitions (Appendix A). Identification of the most

appropriate level of care for each client will inform the amount of therapy each client will receive. For

example, if a client’s care needs align with the definition for Short-Term Complex Medical Management

level of care, the corresponding therapy provision will be based on the Short-Term Complex Medical

Management level of care therapy recommendations. This includes recommendations for therapy

frequency, discharges indicators, expected LOS, and required involvement of an interprofessional team. It

is essential each client receiving rehabilitative care be informed of the frequency of rehabilitation they

will receive in order to improve, according to provincial standards.

Adherence to this strategy will ensure regional facilities and the North West LHIN align with the

provincial standards for the provision of rehabilitative care. Overall, clients will receive the same care

regardless of where they reside within Ontario, as recommended by the Auditor General in 2013. It will

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also assist in improved communication between clients, families, and caregivers regarding expected care

provision and create clear expectations for both clients and service providers.

Use of Technology in Care Provision

The care system in NWO has developed to provide service in innovative ways given the geographic

challenges. One of the biggest strengths of the North West LHIN is the availability and utilization of

technology to enhance care provision. While opportunities for utilization of technology continue to be

explored for rehabilitation, the availability of virtual care constitutes a significant strength. It is

recommended the use of technology to enhance care provision continue and be expanded where

appropriate. It is also recommended partnerships between Ontario Telemedicine Network (OTN),

Keewaytinook Okimakanak Telemedicine (KOTM), rural and remote northern locations and regional

partners, and care providers be utilized and nurtured to ensure the platform is used to its full capacity.

Using this available technology, several specialized programs are currently delivered throughout NWO,

providing care otherwise unavailable for many clients. Current programs and associated videoconference

processes are in place to support regional self-management education and exercise groups such as the

MOST program for stroke survivors and the Healthy Lifestyles program for specialized cardiac

rehabilitation. Both programs are delivered locally in Thunder Bay and available within most healthcare

facilities across the region via videoconference access. The desired future state will explore further

opportunities to deliver specialized programming locally with videoconferencing support and evaluate the

potential amalgamation of components of this programming, as appropriate.

104

Other technological platforms currently in place include OTN PCVC and “guest link”, which allow direct,

face-to-face video access between clients and clinicians who may be hundreds of kilometers apart. The

PCVC platform enables individual assessment and treatment through secure online connections from any

network connection: at home or in regional healthcare facilities, including nursing stations. Currently,

these technologies are being utilized to provide regional access to speech language therapy, wound care

consultations, fracture clinic appointments, and occasionally other assessments.

The PCVC technology supports a regional aphasia strategy. In response to limited availability of adult

outpatient SLP, a program was recently implemented at SJH to enable an outpatient SLP in Thunder Bay

to provide services to clients within remote communities through the guest-link system. This now permits

clients to return home and still access the care needed in the appropriate environment rather than being in

hospital. In fact, the opportunity to remain in a home environment while acquiring the necessary skills for

ongoing recovery allows people to practice speech skills on a daily basis.

Regional wound care consultations are another service provided at SJH using the PCVC technology. The

specialized wound care team includes: the client and a local health service provider to provide the

recommended care such as dressing changes, a registered nurse, a physician, and access to an OT, PT,

Social Worker and Chiropodist as required. The program leverages client appointments in Thunder Bay to

see the client in person but most of the care recommendations are conducted in the LHH with the

telemedicine nurse or using a secure OTN portal to upload pictures of the wound. Some clients are not

even required to leave their own home.

Another significant strength in NWO is the utilization of telemedicine visits for fracture clinic

appointments, health promotion, and follow-up. The use of telemedicine for these services prevents

inconvenient, time-consuming, expensive, and often difficult trips. With increased access for regional

clients, this service allows people to return to their home communities with the confidence their needs

will be met. Utilization of technology and the telemedicine infrastructure will continue to enhance the

ability of clients to remain in their homes or in their local community while receiving more specialized

care.

In order for individual video assessment and treatments to occur, there must be coordination of equipment

and the availability of dedicated, trained staff (ideally rehabilitation assistant) within each community to

assist with assessment and intervention being recommended by the offsite, treating therapist. These local

needs are one of the primary barriers to increased uptake of technology-based service provision at this

time. In order to increase the utilization of technology-based service provision, dedicated clinical and

clerical resources to provide remote care provision are required. Utilization of technology in conjunction

with the Rehabilitative Care Lead organization and Care Stream approach will enhance the access to

specialized care across the region and ensure every client in NWO has access to a minimum level of


105

Remote North Access to Care

In addition to the recommendations made throughout the described future state of rehabilitative care in

NWO, special consideration must be made to ensure equitable access to care is made available to clients

who live in remote and rural areas who do not currently have access to rehabilitative care within their

community. Despite small successful initiatives and several attempts to implement rehabilitative care

within Northern remote communities, there is ongoing difficulty with the development of a sustainable

model for rehabilitative care. At present, provision of rehabilitation services in remote communities range

from non-existent to very limited and funding for transportation is not available through the NIHB

program for clients who require assessment and intervention from an allied healthcare provider.

The inability to sustain consistent service provision within remote and rural communities is due to several

factors. One factor is the availability of local, trained, skilled service providers, as demonstrated by the

VON exercise programs. VON currently has a mandate of providing strength, balance, and falls

prevention programs to seniors within NWO. In 2014-2016, these programs have been unavailable in

remote Aboriginal communities due to inability to hire local employees. The VON program has the

capacity to provide fall prevention classes in remote communities using laptops and videos prepared by a

registered healthcare professional, but without adequate local support of an exercise lead, implementation

of this program has not been possible.

A similar finding was observed through the Assess and Restore First Nations Capacity Building project

completed in April 2015. The primary focus of this project was the development of a community-based

model to maintain activity for seniors and others living with chronic health conditions. The pilot project

included the development and implementation of a holistic, health-based afternoon program including an

exercise session with support from workers with the North Caribou Lake Home and Community Care

program. The afternoon provided an example of an effective rehabilitative care program within the North

Caribou Lake community. Presently, no further care has been provided in follow-up to this program;

however, a series of recommendations were developed. In order to build a sustainable program, the First

Nations Capacity Building project recommended development of partnerships with current service

providers within remote communities using the HCCP in order to increase their role in delivering exercise

programming.

106

The role of utilizing existing home care providers within local communities is well established in other

parts of Canada. Currently, this model of care is used in Nunavut and involves training community

therapists through the University of Winnipeg. These trained service providers are able to assist with the

implementation of exercises, facilitation of remote assessments, and provision of personal care services.

Through stakeholder engagement sessions, the utilization of local service providers to facilitate access to

rehabilitative care was further supported. It was recommended local service providers, with training as

personal support workers, would enable a sense of trust between the client and regulated healthcare

provider. This would facilitate participation in the assessment and treatment as well as bridging cultural

differences including language.

First and foremost, it must be confirmed that provision of rehabilitative care to remote and rural

communities is a Northern IDN objective. Current infrastructure and cultural services at Meno Ya Win

attest to their experience and expertise working in partnership with the Aboriginal communities in the

Northern IDN. Training and staff development for community care providers need to involve regulated

healthcare providers for rehabilitative care assessment and exercise prescription. It is recommended the

identified Rehabilitative Care Lead organization and Care Streams interprofessional teams partner with

Meno Ya Win to provide the necessary training and education for community healthcare providers.

Prior to the implementation of any training or service delivery model, an in-person engagement session

with each remote and rural community is required. It has been identified the adaptation of regional care

models to provide care in remote northern communities is often unsuccessful. In order to gain the trust,

commitment, and ongoing partnership with each community, a service delivery model must be developed

to meet the needs of individual communities. Community involvement in the development and delivery is

key to the success and sustainability of the model of care.

First, a detailed inventory of available resources within each community is required in order to attain the

benefits identified using existing community resources. In addition, it is important to ensure adequate

resources are available to provide rehabilitative care. It is anticipated additional Personal Support Worker

(PSW) or HCCP trained staff would be required. It is recommended rehabilitative care training be

provided for new and existing support care workers to enable their participation in rehabilitative care-

based assessments and interventions. To complement this initial training, it is recommended these

individuals have ongoing education and training with respect to best practices in care, and the

fundamentals of providing rehabilitative care exercises.

The long-term sustainability of any model of service delivery in NWO is dependent on the utilization of

technology-based care platforms. Through services such as OTN, KOTM, PCVC, and ‘guestlink’, service

providers will be able to provide assessment and treatment from a remote location, preventing the need

for extensive travel. This system of remote assessment and treatment is similar to the recommended

system to support access to specialized care within LHHs, and will require the use of a trained

rehabilitative assistant or service provider to provide on-site assistance for client assessments.

107

Overall, the recommended service delivery model for rehabilitative care in the rural and remote areas of

NWO will require significant communication, coordination, stable human resources, and reliance on

technology. Once rehabilitative care service delivery has been confirmed as a priority in the rural and

remote areas of NWO, there is an opportunity for the Regional Rehabilitation Lead organization to

partner with the rural and remote communities and Health Canada’s FNIHB. This equal partnership

throughout development is essential for the success of any program. Finally, funding agencies must

recognize and approve rehabilitative care, resources must be shared across care models, and

communication between care provision and funding organizations will be required.

Francophone Access to Care

Every person deserves healthcare to be provided in a culturally safe way. The North West LHIN has a

multi-cultural population and every attempt should be made to provide care, documentation, and

information in the person’s first language. Specific to the North West LHIN, there is a significant

Aboriginal population noted above and although not as large, there is a sizable Francophone population,

especially in the District of Thunder Bay (13%). Engagement with this population has demonstrated they

are accustomed to service not being provided in their own language and consequently don’t often

complain. Therefore, it is recommended clients, whose first language is French, be identified as French

speaking and actively offered health service delivery in their first language. Health service providers

should self-identify their own staff who are Francophone or who have the ability to provide service using

the French language and every effort should be made to match the resources appropriately with clients.

As with all clients, care must be taken at times of transitions along the care continuum to ensure

information is accurately transferred in both languages to the next stage of rehabilitative care.

Francophone clients often prefer any documentation be provided in both English and French as they may

often only know the English word for healthcare terms. In addition, it is recommended any forms or

website information are accessible in both English and French. When internal healthcare providers are

unable to meet the needs of a Francophone client, it is recommended providers access the free healthcare

interpretation service L’accueil francophone for both accompaniment and translation services. These

services are available either in person or via telemedicine platforms.

It is recommended to continue working in partnership with the French Language Services Health

Planning at the North West LHIN to build capacity and disseminate the resources for the needs of this

population in order to provide accessible rehabilitative care throughout the North West LHIN.

Performance Measurement

The RCA and the MOHLTC have collectively identified outcomes that are to be achieved through

rehabilitation restructuring. The work of the Rehabilitative Care Regional Program will contribute to the

achievement of these outcomes for the North West LHIN. It is recognized progress toward these system

level outcomes will be slow but deliberate. Process and outcome measures will be identified to track

overall progress on the implementation of this plan. At the time of writing this plan, significant work on

data and performance indicators was still underway at the provincial level. These indicators will be

incorporated into the plan as they are developed.

108

Recommendations

Throughout the planning process, the complexity of moving from a current state to a future state delivery

model was discussed by committee members, care providers, and subject matter experts. It was

recommended that an incremental approach to implementation be adopted, first, addressing current

challenges and then build on current outreach programs. It was also recommended the model be scalable

and incremental, starting with the use of early adopter sites and initiatives where activity could slowly be

increased and evaluated in order to ensure changes are producing desired results.

In order to facilitate the transition to an integrated rehabilitative care model, a series of recommendations

have been developed. These recommendations are designed to meet the overall strategic priorities

required to improve rehabilitative care across the North West LHIN. With each recommendation, a series

of action items have been outlined to guide the specific changes required. Each action plan is

accompanied by a timeline within a three-year period. Within each action plan, the healthcare level

directly involved, as well as the specific deliverables and expected outcomes, have been identified (Table

34). Overall, the list of outcomes will demonstrate the key elements to be represented within the future

state model of rehabilitative care.

The following recommendations were developed to support the transition to an integrated model of

rehabilitative care. Through the implementation of the recommendations, it is anticipated clients across

the region will experience improved access to rehabilitative care services and flow through the

rehabilitative care system. In addition, access to specialized care, coordination, collaboration and

knowledge will improve for both clients and clinicians across the region.

109

Table 34. Implementation Plan


Level Deliverables Outcomes Status

Recommendation #1

Improve client experience and outcomes through the implementation of the RCA definitions framework to align rehabilitative care in the North West LHIN with the

provincial framework

1.1 Ensure there is regional alignment with

the RCA definitions frameworks for

bedded and community-based levels of

rehabilitative care

• Provincial

• Regional

• RCA Bedded and Community

Mapping Tool results

• Full alignment with approved

exceptions


1.2 Educate service providers regarding the

definitions

• Regional

• IDN

• LHH

• Education module on

rehabilitative levels of care

• Education module delivered in all

hospitals throughout North West

LHIN

• Increased knowledge &

understanding of rehabilitative levels

of care

1.3 Create an implementation schedule to

achieve alignment with RCA definitions

by March 2017

• LHIN

• IDN

• LHH

• Implementation Plan • Full alignment by March 31, 2017


1.4 Upon referral, establish a process to

determine the appropriate level of

rehabilitative care for each client and

the appropriate location of rehabilitative

care i.e. LHH, IDN and the region

• Regional

• IDN

• LHH

• Care stream process map

developed and shared throughout

the LHIN

• Regional Rehab referral system

piloted in 2 IDNs




1.5 Confirm the required health human

resources to provide each level of care

and the capacity of each health hub and

integrated network to provide the level

of care

• LHIN • Capacity Plan • Quality, evidence-based care



1.6 Establish a process to gather

information regarding the rehabilitative

• LHIN • RCA Bedded and Community

Mapping Tool



110



care provided by regional hospitals on

their inpatient unit.

• Completed community

engagement profile

• Regional Rehabilitation Health

Human Resources Table

• Capacity planning completed at the

LHH and IDN levels

1.7 Maximize Convalescent Care Bed use

to align with Activation/Restoration

Bedded Levels of Care by addressing

process issues related to barriers such as

IV medications, staffing resources, and

discharge location determination

• LHIN

• IDN

• LHH

• Working group established

between stakeholders to identify

and address barriers

• Process map developed and

shared throughout region

• Full alignment with

Activation/Restoration Level of Care

in IDNs with CCB



Recommendation #2

Develop a LHIN-wide strategy to improve client access and client transitions across the continuum of rehabilitative care

2.1. Review current or create appropriate

diagnosis-specific client care pathways

based on best practices to support the

access and transition between inpatient

and outpatient services across the entire

North West region

• Regional

• Care Pathways

• QBP Heat Map for stroke, TKR,

THR, Hip #

• Care stream Leads established

• Appropriate LOS

• QBP optimization


• Improved client/care transitions


• Care close to home

2.2 Develop a plan and implementation

strategy to improve transitions between

specialized rehabilitation services and

local services at either the IDN or LHH

level and transitions home

• Regional • Discharge process map

• Discharge checklist

• Standardized documentation

• Standardized referral form across

regional/IDN/LHH

• Standardized process for

accessing OT home visits post

discharge from hospitals



• Clear documentation

• Enhanced communication among

providers

2.3 Improve direct access from primary care

and community care providers to both

inpatient and outpatient/community-

based rehabilitation programs

throughout the region

• LHIN

• IDN

• LHH

• Care pathways established:

community-hospital-community

• Coordinated referral management

system for rehabilitative care


• Decrease unnecessary ER/acute care

visits


• Decrease ALC for LTC

111



• Memorandum of agreement with

FHTs

• Frail Senior/Medically Complex

Care stream Lead

• Care close to home as soon as

possible

2.4 Evaluate opportunities for the

development specialized outpatient

programs to be delivered closer to home,

building on successful regional models

• Regional

• IDN

• LHH

• Care Stream Leads

• Specialized OP programs

delivered at IDN/LHH

• Provision of local temporary

housing as necessary




2.5 Strengthen connections between local

service providers and regional care

networks to provide support for LHH

provision of rehabilitative care

• Regional

• IDN

• LHH

• Annual Retreat

• Care Leads

• Health Human Resources Contact

List

• Enhanced communication amongst

providers






information regarding and access to

visiting specialists programs to support

an integrated regional model of

specialized client care

• LHIN

• FHT

• IDN

• LHH

• Visiting specialist program

integration





Recommendation #3

Facilitate adherence to best practices for rehabilitative care to improve client-centred care

3.1 Build capacity to meet best practice and

QBP expectations at a local level though

knowledge-sharing across the region

• Regional

• IDN

• LHH

• Annual Retreat


• Website

• Full QBP funding





112



3.2 Strengthen and expand existing clinical

practice networks for rehabilitative care

providers to ensure an integrated model

exists across the Northwest

• Regional

• IDN

• LHH

• Annual Retreat


• Website



• Enhanced communication amongst

providers




information regarding best practices for

rehabilitative care throughout the region

(such as website and/or care streams

leads)

• Regional

• IDN

• LHH

• Annual Retreat


• Website





Recommendation #4

Enhance utilization of innovative technologies to improve access to rehabilitative care services closer to home, particularly in remote and underserviced areas

4.1 Develop a process to support and

expand access to assessment and

treatments with regulated healthcare

providers in communities where

regulated health providers are not

available

• Regional

• IDN

• LHH

• Care Streams Leads

• Rehabilitation Training for PSWs/

Therapy Assistants

• Discharge Process Map

• Appropriate Care following

Regulatory College Standards

• Community Exercise in Far North

• Rehabilitation in 10/39 Far North

Communities







providers

4.2 Evaluate opportunities and review the

feasibility of integration of specialized

programs delivered using technology

• LHIN

• Regional

• One exercise program per LHH

(depending on demand)

• Efficient resource utilization

• Streamlined service delivery



113



4.3 Support provincial and LHIN initiatives

for a shared Electronic Medical Record

• LHIN • Shared EMR • Improved quality of care


providers

Recommendation #5

Develop and implement data collection and evaluation systems for quality of care monitoring and continuous quality improvement to improve resource efficiencies

for the provision of client-centred care

5.1 Review existing reporting

mechanisms and provide advice

regarding how to improve data

accuracy and quality to support

future decision-making regarding


• Provincial

• LHIN


regarding key indicators; collect

and monitor key indicators

• OP Minimal Data Set

• Accurate quality data

• Improved decision making regarding

rehabilitative care needs

5.2 Provide training and assist in the

implementation of data collection

systems for outpatient programs to

align with RCA minimum data set

recommendations, including care

outcomes, experience and cost.

• Provincial

• Regional


regarding key indicators; collect

and monitor key indicators

• OP Minimal Data Set Tool kit

• Accurate quality data to inform

decision making

5.4 Monitor and measure overall system

performance

• Provincial

• LHIN

• Rehabilitation Score Card

• Evaluation of referral

management system




• Efficient resource use

5.4 Using RCA tools, measure the client

progress and care experience in each

rehabilitative care setting

• Provincial

• LHIN

• Regional

• Key indicator data sets • Quality, evidence-based care




114

Next Steps

The implementation of the integrated model of rehabilitative care in NWO and recommendations

identified in this report will be led by the Regional Rehabilitative Care Lead Organization in partnership

with the North West LHIN. It is essential the lead organization is clearly identified and has an

accountability agreement with the North West LHIN. Following announcement of the Rehabilitative Care

Lead Organization, engagement of the Chief Executive Officers of the North West LHIN hospitals will be

essential, and a Rehabilitative Care Advisory Committee will be established. This committee will include

regional stakeholders and participation across all levels of rehabilitative care including client and family

representation, clinician representation, and administration representation. The advisory committee will

be established in conjunction with the Rehabilitative Care Lead Organization in order to drive an

implementation plan for each recommendation and outlined action plan. It is expected the Rehabilitative

Care Lead Organization and Rehabilitative Care Advisory group will be established in 2017. The

membership requirements and terms of reference will provide a foundation for the establishment of this

specific rehabilitative care advisory group.

Between 2017 and 2020, all publicly-funded rehabilitation providers will be expected to participate in the

implementation phase of the rehabilitative care review. It is essential all organizations identify a

rehabilitation champion who will assist with the ongoing development of rehabilitative care and adoption

of recommended changes within their organization.

Stakeholder Engagement

Throughout the implementation of the recommendations and action plans, it is imperative there is

ongoing stakeholder engagement. In order for the recommendations to be successfully implemented, and

the overall rehabilitative care system in NWO to improve, every level of stakeholder must be involved.

Recommended stakeholder sessions will be provided within each LHH throughout the implementation

with specific focus groups held for care recipients/local citizens, clinicians, supporting agencies, primary

healthcare providers, and administration. In addition, region-specific engagement will be required to

focus on the challenges of access for the most remote locations within the North West LHIN.

Members of the Rehabilitative Care Advisory Committee and designated rehabilitative care champions

within each facility will be expected to participate in ongoing stakeholder engagement. These individuals

will be responsible for communicating any changes and expectations identified by the Rehabilitative Care

Advisory group, as well as bringing forward recommendations to support further integration and

improvement identified by front line staff, clients, and families.

115

Timelines

A three-year timeline has been established for implementation of the identified recommendations. This

timeframe will ensure the accuracy of information obtained during this review and allow for an

incremental implementation, reflecting the complex nature of the healthcare system and the requirement

to evaluate progress and adjust development accordingly. It is anticipated some changes will be required

due to ongoing healthcare developments in the province; however, a three-year timeline to initiate all

identified action plans will provide a strong momentum for change and development of a foundation from

which to continue to monitor and evaluate ongoing needs.

As discussed, a phased approach will be used throughout the implementation of the integrated

rehabilitation system. This will allow opportunity to initiate small components using Plan-Do-Study-Act

cycles, or Continuous Quality Improvement to spread the initiatives across the region, evaluate the

implementation progress, and adjust the timelines and action plans as required. Within the first year of

implementation, it is expected the advisory committee will evaluate the recommended year one action

plans and work to develop required working groups with resources outside of the committee, and action

plans for the execution of the priority projects. The Gantt chart depicted in Figure 8 presents a proposed

implementation schedule through to the end of the 2019-2020 fiscal year.

Within the Phase I Post-acute Care report, several recommendations were developed to help guide the

development of the integrated model of rehabilitative care. This review focused on priority rehabilitative

care areas, but additional recommendations will be important to the overall success of implementing an

integrated model of rehabilitative care. Specifically, the Rehabilitative Care Advisory Committee should

address the following recommendations:

• The examination of utilization/reallocation of LTC/EldCap/CCC beds located outside the City of

Thunder Bay.

• Examine activity that is by definition “rehabilitative care” currently being provided by acute care

facilities and make recommendations regarding appropriate sponsorship of these services.

116

Figure 9. Gantt Chart of Proposed Implementation of Rehabilitative Care Regional Program

May

-16

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-16

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g-1

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-16

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v-1

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Jan

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-17

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-17

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v-1

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Dec

-17

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-18

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Educate Stakeholders on RCA Definitions Frameworks

Review ability of each facility to provide identified therapy intensities

Implement care stream and applicable flow maps

Develop a communication system between clinicians to improve transitions between regional sites

Review current diagnosis specific client care pathways based on best practices across NOW

Develop specialized Interprofessional care teams and leads within each care stream

Establish connections between service providers and regional care networks

Identify and facilitate access to a minimum basket of services including equipment

Develop a process to determine individual levels of care

Build capacity to meet best practice and QBP expectations at a local level

Deliver rehabilitation professionals annual retreat/forum

Expand the role of care stream teams to increase regional access to specialized care

Improve direct access from primary care and community care provider to rehab programs

Participate within LHH and regional forums to address ALC, supportive housing and community supports

Support provision of shared EMR

Refinement of roles within Care Stream Model

Establish the delivery of one community-based exercise program per LHH

Evaluate clients who were referred to streams of care

Implement electronic referal management system

Implement rehabilitative Care delivery model to remote North communities

Develop and share Rehabilitation Score Card

117

Conclusions

The regional rehabilitative care plan is the result of years of ongoing discussion and evaluations. This

plan has been developed with the insight from both local and provincial rehabilitative care capacity-

planning exercises. Using these findings and building on the Post-Acute Review Phase I Report, the

recommendations developed within this capacity planning exercise will provide strategic direction to the

overall re-design of an integrated rehabilitative care system in NWO. By aligning the 2016-2019 IHSP

and Health Services Blueprint in the North West LHIN, the recommended integrated model of

rehabilitative care will flow seamlessly within the overall integrated health system network in the North

West LHIN.

The high level recommendations identified within this capacity planning review will not only advance the

effectiveness of rehabilitative care within NWO, but will ultimately improve the overall quality of

rehabilitative care and client experience within the rehabilitative care system.

Rehabilitative care is currently provided within a variety of inpatient, outpatient, and community care

settings, often with little support and coordination between facilities. While each organization endeavours

to provide the best care possible for their clients, gaps remain with respect to ensuring equal service is

available to all residents in the region. As such, there are identified areas of concern with respect to

accessing best practices and adhering to QBP’s, client transitions between locations and levels of care,

and collecting and interpreting quantitative data to evaluate care provision across the region.

Implementation of the identified recommendations and action plans will result in a coordinated regional

model of rehabilitative care. Through individual organization contributions and collaborative regional

efforts, the North West LHIN will be well positioned to align with provincial standards for rehabilitative

care and improve the care journey for clients requiring rehabilitation. Through ongoing partnerships with

the RCA, the North West LHIN will continue to ensure the unique needs of our region are addressed on a

provincial level, and our successes continue to be showcased as a leader in remote/regional rehabilitative

care provision.

By building on the existing passion and commitment to meet the unique rehabilitation needs of our

clients, the North West LHIN will continue to demonstrate excellence in care provision. The use of

technology, development of care networks, and partnerships with our remote communities will continue

to enhance our care provision, and in turn assist to develop a strong, lasting, integrated system of

rehabilitative care.

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recommendations/clinical-handbooks.


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recommendations/clinical-handbooks

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Ontario, 2013. Available:

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Ontario Hospital Association. (2012). Local Health Hubs for Rural and Northern Communities:

An Integrated Service Delivery Model Whose Time Has Come. Toronto, 2012.

Ontario Hospital Association. Optimizing the Role of Complex Continuing Care and

Rehabilitation in the Transformation of the Health Care Delivery System. Toronto, May 2006.

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Based Procedures. Toronto, 2013.

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(Online). Toronto, 2014. Available:

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rk_for_Bedded_Levels_of_Rehabilitative_Care__FINAL_Dec_2014_.pdf

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Rehabilitative Care (Online). Toronto, March 2015. Available:

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15/Definitions/Def_Framework_for_Community_Based_Levels_of_Rehabilitative_Care__Final

_March_2015_.pdf

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[Toronto], 2015. Available: www.rehabilitationcarealliance.ca/mandate-1-final-report

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http://www.rehabcarealliance.ca/mandate-1-final-report

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15/OPAMB/Technical_Report_describing_the_data_elements_within_the_Access_and_Transiti

on_and_Financial_Quadrants_of_the_MDS.pdf

Sinha, SK. (2012). Living Longer, Living Well. Toronto (December, 2012).

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LHIN. Unpublished Document. August, 2014.

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Factor: 0.77.

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HospitalFundingENG.sflb.ashx

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123

Assess and Restore. North West LHIN Small Hospital Review and Capacity-Building Project

Final Report. April 2015.

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Rehabilitative Care for People with Complex Health Conditions: the Time is Now (page 2).


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Levy.pdf

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five Integrated District Networks. Thunder Bay, 2015

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124

Appendix A – Rehabilitative Care Alliance Bedded Levels of Rehabilitative Care Definitions Framework

125

126

127

128

129

130

131

132

133

134

135

136

137

Appendix B – Rehabilitative Care Alliance: Definitions for Community-Based Levels of Rehabilitative Care

138

139

140

141

142

143

144

145

146

Appendix C – Rehabilitative Care Alliance Capacity Planning Framework

147

Appendix D – Rehabilitation Care Alliance Planning Considerations for Reclassification of Rehabilitation/CCC beds

Project Charter

148

Appendix D – Project Charter

Project Charter

North West LHIN: Post-Acute Review (Integrated Model of

Rehabilitative Care)

Project Charter

149

Revision History

Revision Date Status Author Reviewed By Summary of Changes

V0.1 2015-02-24 Draft John Clack Kathleen Lynch Updated Governance Structure, modified roles of

Rehab Care Alliance.

V0.2 2015-04-16 Draft John Clack Kathleen Lynch Updated Background, Scope, Governance

Structure, and Goals

V 0.3 2015-04-21 Draft John Clack St. Joseph’s Care

Group Leadership

Team

Modified Title, Updated Scope, Updated Goals,

Adjusted Timeline

V1.0 Approved Updated as the approved first version by Sponsor

Document Approval List

Version Approved By Signature Date

V1.0 Name, Project Sponsor [Date]

V1.0 North West LHIN Senior Team [Date]

Document Distribution List

Name of Receiver / Group Date

[Senior Team] [Date]

[Project Steering Committee Name] [Date]

Change Request Log

Change Requests Approved By Signature Date Approved

[Name of Change Request; include hyperlink to

document in SharePoint]

[Date]

Project Charter

150

Project Name: North West LHIN Post-Acute Care Review Target Start Date: [April 1, 2015]

Project Sponsor: NW LHIN Target Completion Date: [April 1, 2016]

Project Manager: John Clack Coordinating Constituent (North West LHIN or HSP

leading the project): NW LHIN and St. Joseph’s

Care Group

North West LHIN Coordinating Department (select one): ☐ CEO Office ☐ Communications ☐ Corporate Services

☐ HST ☐ Health System Design & Development ☐ Health System Development & Integration

☐ HSP ☐ PCA ☐ eHealth/PMO

Purpose Statement

Explain the purpose of this project by describing, at a high-level, the background necessary to understand why the

project was started, what will be done. What is this project aiming to achieve? What is its vision? What need or

opportunity will it address? What problem will it solve?

Purpose

The purpose of this project is to complete a detailed capacity planning review of rehabilitative care across Northwestern

Ontario (NWO) in order to develop a comprehensive integrated service delivery model. Specifically, a review of the

current state of Complex Continuing Care (CCC) and Rehabilitation (jointly referred to as rehabilitative care) will be

completed in order to identify best practices and models of care required to develop an integrated regional rehabilitative

care system led by an identified regional lead.

The primary focus of this project will be the development of an integrated approach to the delivery of rehabilitative

care in NWO. Initial stages will include the utilization of existing capacity planning tools and common definitions

developed by the Rehabilitative Care Alliance (RCA)1. These tools will provide a guideline for a detailed capacity

planning process which will include a review of the current state and development of an ideal future state of

rehabilitative care in NWO. These reviews will be utilized to identify gaps in service across the continuum of

rehabilitative care in the region, and will inform the development of an integrated hub and spoke model of care.

Specifically, this model will be designed to meet current best practices and align with identified levels of care.

1 Rehabilitative Care Alliance. Inspiring New Directions in Rehabilitative Care (2015). Accessed At:

http://www.rehabcarealliance.ca/uploads/File/Final_Report_2013-15/RCA_Final_Report_2015__FINAL_.pdf

Project Charter

151

Through the identification of gaps in current services, elimination of service duplication and streamlining of referrals, a

more efficient use of available resources will be achieved. Collaboration between the North West LHIN, St. Joseph’s

Care Group (SJCG), Thunder Bay Regional Health Sciences Center (TBRHSC), North West Community Care Access

Center (CCAC), and regional health care providers will be integral in the optimal utilization of services and ultimate

improvement in patient/client experience. Through an integrated service delivery model, the region will experience

improved efficiency, quality, and cost-effective health care with the benefit of services delivered as close to home as

possible.

Within the development of an integrated service model, based on best practice guidelines, this review will examine

bedded levels of care, outpatient and ambulatory rehabilitative care, and community based programs across the region.

Further, it will identify strengths in current care provision in order to reach remote communities across the region, and

ensure provision of services as close to home as possible.

Background

The importance of rehabilitation within the global context of health care has been well documented2. In light of the

ongoing changes and increased demand placed on the health care system, it has become increasingly important to

identify optimal care practices and efficiencies. In recent years, the NW LHIN has conducted ongoing evaluations of

health care practices in order to develop a strategy to meet changing needs3.

Within the NW LHIN, there is a strong demand for rehabilitative care services and programs. Historically, these services

have primarily been based out of the City of Thunder Bay with 60% of the CCC bed capacity and 100% of the

rehabilitative care bed capacity located in within the City of Thunder Bay. While these services have met the needs of

many residents of NWO, it has been identified that gaps remain within the current system that limit access to quality

rehabilitative care for some residents in NWO.

Demand for rehabilitation services in NWO is expected to increase significantly as our population continues to age. It

2 Office of the Auditor General of Ontario. 2013 Annual Report. (2013). Accessed at:

http://www.auditor.on.ca/en/reports_en.en13/2013ar_en_web.pdf

3 Yahn J., FarrellS. (2012). North West LHIN Regional Rehabilitation and Complex Continuing Care Final Report and

Recommendations.

Project Charter

152

is expected that over the next 10 years, the population aged 65 to 79 will increase by 42 percent in the region4. In

addition, it has been demonstrated that with increased average age of care recipients, there is a related increase in

chronicity and complexity of medical conditions and a disproportionate increase in demand for healthcare. Based on

these factors, it is expected that there will be an even greater demand placed on rehabilitation and restoration services,

prevention, and maintenance of health as a means of stability within the health care system.

In 2012 a detailed review of Rehabilitation and CCC in NWO was completed. This review included both quantitative

and qualitative evaluations of rehabilitative care from 2009-2011. Further evaluation was completed prior to the 2013

development of the NW LHIN health service blueprint, which outlined a need for increased integration across the region

with respect to care provision. From these documents, the LHIN and SJCG completed a phase one review of post-acute

rehabilitative care services which was submitted to the LHIN in August 2014. This document provided an initial

evaluation of services across the NW LHIN and a starting point for this review.

Literature Review:

Recent literature on innovative rehabilitative care models has largely focused on the concept of vertical integration and

the utilization of health hub models. Across Canada, and internationally, there has been an increased emphasis on the

utilization of a hub model for health care provision in rural and remote communities5. To date, these models have

primarily been utilized in broad healthcare systems that include the full spectrum of care from primary and

acute/emergency through rehabilitative care. Such models however can also be directly utilized in a more defined scope

such as within a rehabilitative care model. Specifically, the utilization of vertical integration defined as the “integration

of different inter-related or inter-dependent health sector elements on the continuum of care” and may include primary,

secondary and tertiary care6.

A review of current health care practices in remote and rural regions indicates several innovative strategies that have

demonstrated some level of success. Among the most commonly identified strategies are increased utilization of

4 North West LHIN: Health Services Blueprint: Building Our Future. (2012). Accessed at:

http://www.northwestlhin.on.ca/goalsandachievements/Health%20Services%20Blueprint/BlueprintReport.aspx

5 Ontario Hospital Association. Local Health Hubs for Rural and Northern Communities (2012). Accessed at:

http://www.oha.com/KnowledgeCentre/Library/Documents/Local%20Health%20Hubs%20for%20Rural%20and%20No

rthern%20Communities.pdf.

6 Ministry of Health and Long Term Care. The Health Planner’s Toolkit: Module 4 (2006). Accessed at:

http://www.health.gov.on.ca/transformation/providers/information/resources/health_planner/module_4.pdf

Project Charter

153

telemedicine and e-learning for clients and staff, expanded health care provider roles, and utilization of educational

models for disease management and prevention. The most commonly used and well established of these innovative

strategies is the utilization of telemedicine. At present, this service is primarily being used to allow clients access to

physician follow-up from their home community. Research however has indicated a potential for this service to enable

at home rehabilitative care with the support of personal service workers and caregivers allowing them to provide

exercises within the home environment. Further, this system has been utilized in NWO for ongoing community

education and support through programs such as Moving on After Stroke (MOST) and geriatrics consultation. Building

on these successes will create opportunities for specialized rehabilitative consultation and education for remote health

care workers, and the development of a coordinated care network to ensure best practices despite geographic challenges.

Rationale

As outlined in the 2013 NW LHIN Health Services Blueprint, a primary goal is integrated health care services by 2021.

The plan has identified the need for integrated post-acute rehabilitative care services focusing on improving the patient

experience within the healthcare system through a coordinated continuum of services.

A specific focus at this time has been placed on post-acute care services (including Rehabilitative Care,

Ambulatory/outpatient care, and community services). In NWO, regional residents have less access to inpatient

rehabilitation, home care services, post-acute CCC and Long-Term Care (LTC) services in comparison to City of

Thunder Bay residents. As such, it is essential that these services are reviewed and modified such that increased

equitability is available across the region.

Within NWO, the LHIN provides funding for 96 health service providers (HSP). To date, the region has relied as much

as possible on the use of innovative approaches to care, however health provider input has acknowledged duplication,

inconsistencies, and gaps in healthcare services across the region. More significantly, a lack of vision for integration

and communication across levels of care with respect to equitable, system wide access has been identified. These

findings highlight the importance of evaluating current services and creating an integrated systems approach to care

across the region.

These challenges are long-standing and current solutions have failed to meet the needs of communities. The challenges

of providing access to health care have been hindered by several factors such as geographic remoteness, long distances,

low population densities and limited qualified health care providers. The need for a review of the entire system of post-

acute rehabilitative care is required as opposed to a piecemeal approach of trying to meet individual needs of each

community in isolation.

Project Charter

154

Expected Outcomes

It is anticipated that this project will result in the development of an integrated system for rehabilitative care in NWOo.

Within this process both the siting and sizing of rehabilitative programs/services will be examined.

The identified rehabilitative care model will be designed to meet the unique needs of the NW Region specifically,

accounting for the lack of critical mass to implement best practice care in many locations, and the challenge of service

provision in remote parts of the region. The opportunity to use technology and mobile service delivery will be examined

within the model of rehabilitative care.

An integrated system of service delivery will address as appropriate the LHIN blueprint recommendations of7:

- [a model to] organize services and delivery of care at three levels within the NW LHIN: the local, district, and

regional or LHIN-wide (Health Hubs, Integrated District Networks, and Regional Rehabilitative Care Lead)

- The development of networks that provide or arrange to provide a coordinated continuum of services to a target

population.

Fiscally, this review will recommend services across the rehabilitative care continuum throughout the region. It will

additionally inform necessary adjustments to avoid duplication and increase effectiveness in care provision across the

spectrum of rehabilitative care.

Project Scope

Summarize the scope of this project. Then describe ‘what is’ and ‘what is not’ included as part of the work to be

performed on this project. Consider specific features, functions, quality needs or other “must have” requirements and

7 North West LHIN: Health Services Blueprint: Building Our Future. (2012). Accessed at:

http://www.northwestlhin.on.ca/goalsandachievements/Health%20Services%20Blueprint/BlueprintReport.aspx

Project Charter

155

place them in the “IN” scope section. Spell out any exclusions i.e. work that will not be performed, in the “OUT” of

scope section.

“IN” Scope “OUT” of Scope

Describe specific items that WILL be included as part of

the work performed by this project.

Describe specific items that WILL NOT be included as part

of the work performed by this project.

Use of the SJCG Physical Rehabilitation Advisory

Committee as a project governance committee to

provide guidance regarding recommendations for post

acute care in NWO. Additions to the membership as

required will be made to ensure a balanced

representation of members from key stakeholders.

Form sub committees as needed to complete the

work of the Post Acute Review.

Create a clearly defined decision making

process to support the development of a future

state rehabilitation delivery model

Carry out a Current State Analysis: Detailed list of

current service providers across all levels of care:

A detailed environmental scan of current

rehabilitation resources and capacity (including

all inpatient, community based outpatient,

community based services, and outpatient

rehabilitation provided by acute care facilities)

Current referral resources and resources

Current process for transition from pediatric to

adult rehabilitative care

Client demographics

The impact of Quality Based Procedure (QBP)

implementation

Wait times and timeframe to access

rehabilitative care (time from acute admission to

Completion of a detailed current state analysis or

recommendations for acute care provision. Acute care

review will be limited to identifying the number of

clients and length of stay related to these clients who

could be served in a post acute setting.

Inclusion of acute care services within the scope of

this project will be limited to development of

standardized referral processes to rehabilitative care.

This may impact acute care LOS and utilization but

will not impact current rehabilitation care practices.

This project will be limited to a review of physical

rehabilitative care and will not include a detailed

review of mental health care availability and needs in

the region. While it is recognized that there is a role

for mental health care provision within physical

rehabilitation, this will not be the primary focus of

this project. It will however be accounted for in the

assessment of co-morbidities.

Evaluation of the current and future state of palliative

care in NWO will be limited to the current state of

bed allocations, and the impact this has on availability

of rehabilitative care beds. The scope of care provided

for palliative care is beyond the scope of this project.

Focus will remain on rehabilitative care within the

NW LHIN. Evaluation beyond the Northwestern

region will be limited to comparative data in similar

regions and provincial averages.

Project Charter

156

referral and time from referral to rehabilitative

care admission)

Innovative practices currently being utilized

Current capacity and opportunities to achieve

system efficiencies

Current utilization by location and projected

demand for rehabilitative care across the

continuum

Review of current barriers to accessing

rehabilitative care

Volume of service delivered per provider

Review of care being provided outside of the

NW LHIN (including out of province)

Create a Future State and Gap Analysis: Present a

recommended future state of rehabilitative care in the

NW LHIN identifying how to address gaps in service

provision.

A Model of service provision applying the

Health Services Blueprint service delivery

model decision making framework and

definition of basket of services available at the

local Health Hub, District Health campus and

Regional Levels.

Alignment of NWO rehabilitative care services

within levels of care identified through RCA

definitions framework

Future volumes/utilization of services

Identification of opportunities for service

integration

Identification of potential services that can be

carried out at regional locations

Project Charter

157

Identification of opportunities to shift care to

community and identification of the impact

including changes to roles and responsibilities

of care providers

Identification of a plan to address unmet service

needs

Best practice principles applied to decisions

regarding location of service provision

The development of a model for remote

community access

Introduction of innovative practices including

care close to home philosophy

Complete community consultation through Physical

Rehabilitation Advisory Committee

Engage and consult stakeholders throughout the

process in broad geographic regions (Eastern,

Western, Central) and across continuum of

rehabilitative care in order to validate findings

and analyze gaps

Include progress updates to clinicians,

management, leadership and hospital boards as

appropriate.

Develop a LHIN-wide strategy for smooth transition

from Acute Care and across the continuum of

rehabilitative care aligned with other initiatives and

reforms.

Align with work on the Orthopaedic Capacity

Plan, Assess and Restore principles, QBPs for

stroke, hip fracture, and hip/knee replacement,

Physiotherapy reform, Ontario Special Needs

Strategy, and Seniors Health Strategy.

Project Charter

158

Identify/develop clearly defined protocols and

standardized assessments for referrals to and transfers

within rehabilitative care

Apply standardized definitions for levels of

bedded care (utilize RCA Bedded Levels of

Care toolkit)

Explore the benefits and risks of a coordinated

referral and placement process for all

rehabilitative care across the region

Build in strategies to mitigate impacts of

staffing limitations in regional care centers

Identify standardized referral processes across

all facilities (including acute care)

Develop an implementation plan outlining processes

required to reach ideal future state

Identify bed designations (rehabilitation, CCC,

convalescent care) for all facilities

Review patient critical mass and optimal

staffing to provide best quality care

Identify opportunities for innovative care across

region

Confirm the role of Rehabilitative Care

Regional Lead

Ensure cultural appropriateness of programs and

services is accounted for at individual facility

levels

Review progress and plan at small hospital level

for input as needed

Project Charter

159

Carry out a risk assessment including financial

considerations to identify potential impact and barriers

to the successful implementation of the rehabilitative

care integrated service model

Evaluate the impact of HSFR including QBPs

Analyze financial impact on service providers

Identify potential environmental/physical

changes required based on recommended

changes

Establish a detailed evaluation process to monitor

ongoing success and respond to challenges

Appropriateness of referrals

Availability/access to inpatient and outpatient

services across all levels of care

Timeliness of referrals and causes of any

delays/waits

Develop a detailed implementation plan outlining

necessary considerations and steps over 3-5 year

timeframe

Identification of changes in staffing and service

provision for each site

Pilot of small scale versions of recommended

changes at various sites

Consideration of necessary steps for

implementation including staffing changes,

environmental changes, financial impacts

Work with existing review processes to ensure

coordination of post acute services with the Orthopaedic

Project Charter

160

Steering committee, Small Hospitals working group,

Informing Care for seniors, and other current initiatives

Goals, Objectives & Performance Measures

Provide the details of what this project aims to accomplish by listing its specific goals, objectives and deliverables.

State the goals in terms of high-level outcomes to be achieved. Identify specific objectives and deliverables for each

goal listed (reference those identified in your Business Case).

Goals Objectives/Deliverables Performance Measures

List all goals to be achieved by

the project – ensure alignment

with project purpose.

For each goal, list specific objectives

and/or deliverables that will signify

achievement of goal when finished.

Objectives should be the ‘how’ the goal

will be achieved; Deliverables are

concrete products/services/structures

that are produced.

For each objective/deliverable, list the

measures that will be used to evaluate

success of results achieved. Use the

numbering convention shown to link

performance measures to objectives/

deliverables (adjust as needed).

1. Develop guiding principles to

be utilized throughout the

project

A. Work with Physical Rehab

Advisory Committee to develop a

set of guiding principles that will be

followed by all parties involved in

the project

Guiding principles will be

agreed upon by stakeholders

and utilized throughout the

project

All regional care providers

will commit to participating in

a process to develop an

integrated system approach

B. Communication with all regional

partners that an integrated

rehabilitative system, according to

recommended best practices for

care is required

2. Utilize the RCA Capacity

Planning Toolkit to complete

an analysis of the current state

of rehabilitative care in NWO

A. Develop a list of current

rehabilitative care services available

and where clients are being referred

(inpatient rehabilitation, CCC,

Convalescent Care, community and

A detailed list will be

developed including all

regional inpatient, outpatient

and community programs

Project Charter

161

hospital based outpatient programs

and community programs)

A system will be implemented

to ensure the list is updated

according to staffing and

availability changes in

programs over time

B. Evaluate utilization of existing

rehabilitative care system

Comprehensive review of

current service utilization

completed and reviewed for

accuracy by involved

stakeholders

C. Review current referral processes

for rehabilitative care

D. Identify gaps in current service

provision

E. Evaluate current performance of

rehabilitative care (LOS,

readmission rates, client

satisfaction, and recovery rates)

F. Highlight current innovative and

best practices

G. Consult with stakeholders to

validate current state analysis

3. Identify a future state delivery

model for rehabilitative care

A. Complete and validate 2014 survey

results for bedded levels of

rehabilitative care by the RCA

Comparison of

recommendations for best

practices and current practices

utilized to develop ideal future

state projections B. Identify projected rehabilitative

care needs in NWO over the next 5-

10 years

C. Utilize current best practice models

to forecast necessary resources to

meet rehabilitative care needs

D. Confirm the process to access

rehabilitative care (Assess and

Restore) beds directly from the

community/ED

Project Charter

162

E. Develop/identify a referral

management system to ensure

ongoing integration across all levels

of rehabilitative care (Process to

begin in the inpatient care settings)

Development of a coordinated

referral management system

for rehabilitative care

Development/utilization of a

standardized referral form

across all levels of care in

NWO

Identification of

comprehensive evaluation

metrics to evaluate and

monitor effectiveness and

breakdowns of

referral/utilization system

F. Review care structures and

resources/ programs that are needed

to support recommended best

practices

G. Build on the Assess and Restore

process for accessing rehabilitative

care from acute and community

programs (including access to

bedded care, outpatient care,

community care and home based

care)

H. Identify costs strategies to support

required resourcing and geographic

distribution of care as applicable

Development of clear role

definitions for the provision of

rehabilitative care through

Local Health Hubs, Integrated

District Networks, District

Health Campuses, and

Regional lead

Identify innovative strategies

to meet regional care needs

Identify the costs and

environmental changes

required to complete the

proposed plan and adjust the

future model accordingly

based on feedback.

I. Consult with stakeholders to

validate future state model and

ensure accuracy for NW LHIN

4. Develop an action plan for the

implementation of the

integrated model for

rehabilitative care using the

local health hub, IDN and

A. Identify ideal sizing of each level of

the integrated service network

Identification of critical mass

necessary to meet best

practices at each level of care

B. Identification of siting/ designation

of each level of care within the

integrated service network

Determination of the siting of

Regional Rehabilitative Care

lead, care provision levels

Project Charter

163

Regional lead provider

models

within the Integrated District

Health Networks, and Health

Hubs across NWO (Including

confirmation of available

services)

C. Identify lead organization(s) for

coordinated referral system and

targets for accessing rehabilitative

care

Identification of lead

organization to manage

coordinated intake for

rehabilitative care across the

region

Development of a

communication strategy

surrounding definitions and

timeframes for accessing

rehabilitative care (from

community, acute care, and

rehabilitative care facilities)

D. Identification and model for

reclassification of beds completed

and presented to the LHIN if

required

Utilization of the RCA toolkit

for bed reclassification to

ensure optimal care needs are

being met

Identify financial

considerations of

reclassification

E. Align each local rehabilitative care

program within a level of

rehabilitative care from the RCA

definitions framework

F. Provide recommendations for a 3-5

year implementation plan for

integrated rehabilitative care system

Identify necessary

environmental impacts and

operational considerations

required for successful

implementation

Create a timeline for

implementation plan

G. Pilot small scale versions of

recommendation to help identify

challenges

H. Consult with stakeholders on

implementation strategy and

alignment with guiding principles

All regional care providers

will commit to implementation

plan

Project Charter

164

Alignment with Strategic Directions and Priorities

Identify the project’s strategic alignment with the North West LHIN Strategic Directions, Integrated Health Services

Plan (IHSP) priorities, and eHealth Service Plan priorities. Provide an explanation below if needed.

Strategic Directions:

x Improved health outcomes, resulting in healthier people

x Access to health care that people need, as close to home as possible

x Continuous quality improvement

x A system-wide culture of accountability

Integrated Health Services Plan (2013-2016) Priorities:

x Building an integrated health care system

x Building an integrated eHealth framework

eHealth Service Plan Priorities (2013 – 2016):

x Integrate regional electronic health records (EHRs) to improve patient-centred care

x Build regional capacity to accelerate adoption of eHealth systems and technologies to gain system-wide

efficiencies, as rapidly as possible

x Provide innovative technology solutions to improve access to care and health outcomes, resulting in

healthier people

x Improving access to care

x Enhancing chronic disease prevention and management

Description of Alignment (if needed)

This project has been developed in alignment with the strategic initiative of building an integrated health care system.

The anticipated outcomes of an integrated model for rehabilitative care include improved access as close to home as

possible for all patients, while maintaining best practices for care provision. Incorporated in this will be increased

utilization of technology in both service provision for remote communities and in adoption of technologies to improve

communication and reduce duplication of service delivery in the rehabilitative care sector.

Project Charter

165

This project is also aligned with:

Health System Funding Reform – Including Quality Based Procedures Recommendations

Health Quality Ontario Initiatives

Ontario Stroke Network directions

Ontario Renal Network directions

Provincial Palliative Care Planning

Ontario’s Seniors Strategy (Dr. Sinha Report)

Rehabilitative Care Alliance work

Physiotherapy Reform

Provincial Assess and Restore Guidelines

Provincial and North West LHIN - Orthopaedic Capacity Planning

Provincial Resource Matching and Referral Initiative

Health Links

North West LHIN Regional Rehabilitation and Complex Continuing Care Report

2013 Ontario Auditor General Report – Rehabilitative Services at Hospitals

Ontario Seniors Friendly Hospital Initiative

Ontario Special Needs Strategy

Project Benefits

Complete the Benefits Realization in the ‘Benefits Realization, Change Management, Communications Workbook

file’ (in Operations>eHealth>eHealth>Templates>PMO). Identify specific results-based benefits that can be

expected as a result of completing this project.

Project Charter

166

Project Milestones & Timelines

Indicate when the project will take place. Provide a preliminary estimate for the duration of the project by

documenting the target completion dates for high-level project milestones. Milestones are significant project events

that usually signify completion of project phases or major deliverables. In the Planning phase, determine which plans

are required and what level of approval is appropriate for the scale of project you are implementing, in consultation

with your Project Sponsor.

High-Level Milestones

Target

Completion

Dates

North West LHIN

Senior Team

Approval

Required?

List key milestones below. State milestones in past tense to signify

achievement and completion. Include target dates for project kick-off and

project end. The following headings are provided to help you start your list

of milestones.

Provide

preliminary

estimates. Use

‘Month, Year’

format.

Does the North

West LHIN Senior

Team Approve the

Deliverable/Milest

one Completion? Initiation

Project Charter Approved April, 2015 Yes

Planning

Project Timeline Approved April, 2015 Yes

Project Resource Plan Approved May, 2015 Yes

Project Manager hired May, 2015 Yes

Confirmation of Physical Rehab Advisory Group Membership May, 2015 No

Complete Validation of RCA Definitions Alignment Survey June, 2015 No

Project Kick off Meeting (LHIN and coordinator) June, 2015 No

Development of Guiding Principles June, 2015 Yes

Communications Tactical Plan Completed June, 2015 Yes

Governance Model Finalized July, 2015 Yes

Identify Current Rehabilitative Care Program Populations Sept, 2015 No

Project Charter

167

Establish Working Groups/Terms of Reference June - Sept,

2015 No

Develop a 3-5 year projected implementation plan Dec 2016 Yes

Executing

Project Team Members Acquired May, 2015 No

Obtain Data on Program Utilization June, 2015 No

Evaluate Data in Comparison to Current State Aug, 2015 No

Complete Current State Analysis Sept, 2015 No

Complete Future State Analysis Oct, 2015 No

Identification of Ideal Population and critical Mass levels to meet best

practices

Jan, 2016 No

Identification of ideal location for Rehabilitative care LEAD, IDNs, Hubs Feb, 2016 Yes

Finalize proposed changes to current bedded care levels/locations Mar, 2016 Yes

Finalize plan for coordinated referral system Mar, 2016 Yes

Finalize a common referral form for all rehabilitative care Mar, 2016 No

Pilot recommended integrations plan at various sites June, 2016 No

Complete stakeholder feedback session and evaluation following pilot Sept, 2016 No

Monitoring & Controlling

Monthly Project Status Reporting (ongoing throughout project) Ongoing No

Benefits Realization Reconciliation Report Complete [Month, Year] No

Development of an evaluation Metric for coordinated referrals Mar, 2016 No

Evaluate Coordinated referral process Ongoing No

Complete evaluation of proposed integrated system and central referral

process

Sept, 2016 Yes

Closing

Project Charter

168

Lessons Learned Complete Dec, 2016 No

Project Close-Out Report and final recommendations complete

(Senior Team Approval consists of a debrief of the Close-Out report with

Lessons Learned to Senior Team, by Project Sponsor)

Jan, 2017 Yes

Funding Sources

Identify source of funding for this project. Indicate whether project costs will be absorbed by an existing organization

or if separate source of funding is required. Refer to your Business Case to summarize funding sources.

[North West LHIN staff covered by North West LHIN operational budget.]

Project Governance

Show the Governance Structure for the project. Identify the North West LHIN Senior Team, the Project Sponsor, and

Project Manager roles, including the composition of a Steering Committee (if needed), and any other related

governing bodies associated with the project.

Project Charter

169

Table 35 - Governance Roles

Project Governance Role Description of Role

Co-Leads: North West LHIN

(Susan Pilatzke – Sr. Director,

Health System

Transformation) and St.

Joseph’s Care Group

(Kathleen Lynch – Vice

President of Rehabilitative

Care and Chronic Disease

Management)

Formally authorizes the project

Provide senior level direction and oversight

Have ultimate accountability for the success of the project

Presents the project to the North West LHIN and SJCG Senior Teams and

facilitates approval of it.

Provides senior project level direction and oversight to project

Approves:

Post Acute

Review

(Initiated by the

NWLHIN) Project

Manager (John Clack -

Clinical

St. Joseph’s Care

Group Co-Lead

(Kathleen Lynch – Vice

President of Rehabilitative

NW LHIN Co-Lead (Susan Pilatzke - Sr.

Director, Health System

Transformation)

NWLHIN

Project

Support (Heli Mehta , Sr.

Project

Management

and IT

support

Physical Rehab

Advisory

St. Joseph’s

Care Group

Working

Groups (Physical Rehab

Access and

Referral

Bedded

Levels of

Outpatient

Services

Data Analysis Working Group

Project Charter

170

Project Charter

Material/significant changes to Project Scope or Budget

Material/significant increases to Project Resource Requirements

Material/significant increases to Project Schedule (extension to the Project

End Date or extension to Milestone/Deliverable dates that are identified as

requiring Senior Team approval in the Project Charter)

Changes to Senior Team approvals, as identified in Project Charter

Key project milestones/deliverables (identified in the Project Charter as

requiring Senior Team approval)

Project resources, on behalf of their respective organization (i.e. commits

resources)

Budget expenditures beyond sponsor’s signing authority

Project Manager (John Clack,

Clinical Manager - St.

Joseph’s Care Group)

Project Lead (Heli Mehta, Sr.

Planning and Integration

Consultant - NW LHIN)

Presents the project to the NW LHIN and SJCG co-leads, via project charter

Responsible for the successful planning, execution and delivery of the project

within the approved constraints

Active and visible project champion, advocates for its success

Identifies key risks and issues to the project, manages issues to ensure

resolution and mitigates risks to the acceptable risk tolerance levels; escalates

to the Project Sponsor when necessary

Coordinates overall delivery of the project team

Controls the day-to-day activities of the project

Completes regular organizational status reporting, keeping Project Sponsor

informed of project status

Resolves issues and makes decisions in a timely manner

Is the liaison with the Physical Rehabilitation Advisory Committee

Approves:

Project Charter

171

Non-significant changes to Project Scope, Budget, Resource

Requirements,

Non-significant increases to Project Schedule (those that do not extend the

Project End Date or the Milestone/Deliverable dates that are identified as

requiring Senior Team approval in the Project Charter)

Milestones/deliverables, and recommends/endorses approval of key

milestones/deliverables that require Senior Team approval (as identified in

the Project Charter)

Project expenditures within budget and within signing authority

Lessons Learned and Project Close Out Report (provides a debrief to

Senior Team)

Physical Rehabilitation

Advisory Committee

Represents the stakeholders across all sectors of rehabilitative care and regions

throughout Northwestern Ontario.

Formally advises the project on behalf of their region as a whole

Responsible for sharing perspectives and providing direction to project

Engages regional input and perspectives to inform the project

Informally authorizes the project on behalf of their respective organizations

Recommends/endorses changes to project scope and/or timelines

Garners input from stakeholders and represents the interests of all parties

impacted by the project

Provides project updates to relevant stakeholders as deemed appropriate by the

committee and project team

Project and IT support (North

West Health Alliance)

Formally advises the project on behalf of their region as a whole

Responsible for sharing perspectives and providing direction to project

Provides subject matter expertise to the Project Manager and Project Sponsor

in terms of best practices for project delivery

Active and visible project champion, advocates for its success

Identifies key risks and issues to the project and helps mitigate risks to the

acceptable risk tolerance levels

Project Charter

172

Provides technical support and guidance throughout the project planning,

implementation, and evaluation stages

Working Groups (Physical

Rehab Working group and

relevant stakeholders as

required)

Access and Referral Working Group

o Evaluate current referral system for inpatient and outpatient care

o Identify strategies to ensure equitable access to care across the region

Bedded Levels of Care Working Group

o Review RCA definitions for bedded levels of care

o Review validation survey completed by RCA

o Determine utilization of definitions within integrated system

Outpatient Services Working Group

o Review RCA work on minimum data set

o Review current outpatient services and service delivery models

o Identify optimal outpatient service delivery model to meet best

practices

Data Analysis working group

o Review all relevant data to inform current and future state analysis

o Work with other working groups to determine data requirements

o Participate in RCA outpatient minimum data set

implementation/evaluation

Project Team

Identify who is needed on the core project team to complete project deliverables and achieve its goals and objectives.

What skills, knowledge and experiences are required? Consider the need for special expertise to deal with people and

organization change challenges. Use table below to indicate who will be part of the core project team and who will be

brought-in as required. Include resources from partnering organizations as appropriate. Please consider policy,

architecture, and privacy and security domains for resource requirements.

Role on the Project Required Involvement

Project Charter

173

Organizational Role,

Organization Estimated Duration Level of Effort

Provide job titles of team

members and the name of

their organization.

Describe the role & responsibility of

each project team member. Refer to

Appendix A for standard North West

LHIN role definitions – these do not

require a description below.

Indicate target dates

or no. of weeks

/months

Indicate hours per

week/month; include

total hours (based

on 7.5 hours/day)

and total days for

each team member

Project Manager

(Rehabilitation background)

Project Manager

22 Months 37.5 hours/week

(less 5 week

vacation)

Total Hours: 3375

Project Management Support

(Sr. Planning and Integration

Consultant, NW LHIN)

Project Management Support

directly involved in all aspects of

project, representing LHIN

perspective and providing resources

and expertise

22 Months 7.5 hours/week

Total Hours: 712

Project and IT Support (NW

Health Alliance)

Project Support (assist in the

development and implementation of

data and analytics systems and

referral management system)

22 Months 4 hours/week for 12

months

4 hours/week for 10

months

Total Hours: 380

Senior Director, Health

System Transformation,

North West LHIN

Project Sponsor/Lead 22 Months 1 hour/week

Total Hours: 95

St. Joseph’s Care Group

Vice President of

Rehabilitative Care and

Chronic Disease Management

Project Lead 22 Months 1 hours/week

Total Hours: 95

Project Charter

174

Epidemiologist, North West

LHIN

Project Team Member 22 Months 0.5 Day/Month

Total Hours: 88

Communications, North West

LHIN

Project Team Member 22 Months 0.5 hours/Week

Total Hours: 48

Physical Rehabilitation

Advisory Committee

Advisory Committee 22 Months 3 hours/Quarter and

Working Group

Participation as

needed

Total Hours: 35+

Project Charter

175

Project Stakeholders

Stakeholders Interests & Needs

Level of Involvement *

(Inform, Consult, Involve, Collaborate,

Empower)

Identify your

stakeholders.

List names,

groups or

organizations.

Why are they stakeholders? How are they involved? List interests. How will the project manage

expectations & meet their

needs and requirements? relationshi

p to the

project

Level of

Impact on

stake

holder

Level of

influence

on

outcomes

Level of

concern or

interest

Issues of

greatest

concern or

opportunity

How can stakeholder

contribute?

Hospitals

Delivering

Rehabilitative

Care

Direct Positive

Mod-High

High High - Implications

for current and

future care

provision

- Possible

reallocation of

resources/

reclassificatio

n of beds

- Participate in the

gathering/Validation of

data


development and

implementation of future

state

Educate/Inform: specific

regional needs/ challenges/

opportunities at each site.

Consult: provide information

on current service provision

and anticipated capacities for

service.

Involve: directly or indirectly

through Physical

Rehabilitation Advisory

committee, or working groups

Project Charter

176

Collaborate: provide input

on referral design and

evaluation

North West

Community

Care Access

Centers

Direct Positive

High

Mod High -Increased

involvement

in referral

management

system

- Changes in

community

service

provision


gathering/validation of

data


development and


future state

Educate/Inform: Provide

insight on regional needs,

limitations and system

improvements

Consult: provide information

on current service provision

and anticipated capacities for

service.

Involve: through Physical

Rehabilitation Advisory

committee and working

groups.



evaluation methods

Physical

Rehabilitation

Advisory

Committee

Direct Neutral

Mod

High High - Represent

various

stakeholders

- Change in

overall

mandate of

- Represent and provide

recommendations from

various stakeholders

- Participate in

development and

evaluation of future state


information and updates to

stakeholders across the

region.

Ensure that all perspectives

are represented.

Project Charter

177

advisory

committee

- Make decisions and

recommendations

throughout the process

Consult: Share information

between stakeholders they

represent and project

management team.

Involve: Participate in

working groups and monitor

progress of project

Collaborate: Involved in

decision making process

including recommendations

and alternative solutions.

Empower: Will inform but

not make decisions regarding

outcomes.

Inpatient

Rehabilitative

Care

Providers

Direct Positive

and

Negative

High

Moderate High - Bed re-

classification

-Changes in

resource

allocation

- Role in

rehabilitative

care



data


development and


future state


insight on current state, future

capacities and system

improvements

Consult: Provide insights on

recommendations and

improvements.

Involve: Through Physical

Rehab Advisory Committee

and working groups.

Project Charter

178



evaluation methods

Outpatient

Rehabilitative

Care

Providers

Direct Positive

and

Negative

High

Moderate High - Funding

allocation

- Changes in

recommended

service

provision and

care streams



data


development and


future state



capacities and possible

improvements


recommendations and

improvements.



and working groups.

Collaborate: Provide input


evaluation methods

Community

Care Partners

Direct Positive

Mod

Moderate Moderate - Changes in

referral

sources

- Changes in

expectations

of programs

and admission

criteria



data


development and


future state




improvements



and working groups.

Project Charter

179



evaluation methods

CCAC Care

Providers

Direct Positive

and

Negative

Mod

Moderate Moderate - Changes in

service

provision

models and

expected

levels of care



data

- Provide feedback on

recommendations based

on community provider

perspectives




improvements.



and working groups.


on impact of design on

community providers

Hospital

Utilization

Coordinators

Direct Negative

High

Moderate High - Centralized

rehabilitative

care referral

management

system


definition of current state



data


recommendations


development and


state




improvements


recommendations and

implementation.

Involve: Collaborate with

Project Leads in development

and implementation of new

system

Project Charter

180

Physicians

referring to

rehabilitative

care

Direct Positive

and

Negative

High

Moderate High - Changes in

referral

processes


definition of current state



data


recommendations


development and


state




improvements.

Consult: Provide feedback on

Physician utilization of

system.


regarding physician

acceptance

Empower: Will advise and

endorse final

recommendations

MOHLTC Indirect Positive

Min

High High - Increased

integration of

care

- Changes in

resource

allocation

- Contribute data from

peer processes

- Participate in support of

recommendations and

implementation plan


information on similar

projects

Consult: Voice concerns

throughout project

Empower: Will review final

recommendations and endorse

all final decisions

Project Charter

181

Patients Direct Positive

Mod

Moderate Moderate - Improved

flow of care

- decreased

duplication of

services


current state


development of

recommendations and

evaluation of changes


insights from lived

experience.

Collaborate: Representation

on Physical Rehabilitation

Advisory Committee and

working groups

General

Public/Media

Indirect Positive

Low

Low Low - Changes in

resource

allocations

(locations of

care

provision)

It is not anticipated that

this stakeholder will

participate in the project

aside from receiving

communications.

Involvement will be limited to

communications received and

provision of feedback

following implementation of

recommended changes.

Regional

Health

Centers and

Family Health

Teams

Indirect Positive

Mod

Low Moderate - Changes in

referral

process

- Increased

demand for

care close to

home



data


development and


future state




improvements


recommendations and

improvements



and working groups

Project Charter

182



evaluation methods

Ontario

Telemedicine

Network

Direct Positive

Mod

Low Moderate - Increased

reliance on

innovative

strategies



data


capacity and future state

planning


information on available

services

MPP’s Indirect Positive

Low

Low Low - Public

Response to

changes

- Help to disseminate

information to the public

in alignment with

communication strategy.

Will be limited to

communication with

necessary stakeholders as

required throughout the

project

North West

LHIN

Direct Positive

Low

High High - Increased

integration of

care and

decreased

duplication of

services

- Alignment

with health

services

blueprint



data



input

- Provide communication

to external stakeholders

- Support/endorse final

project recommendations


strategic directions and

leadership

Consult: Review all

recommendations and

approve all decisions.

Involve: Represent collective

interests of the region as a

whole

Collaborate: Participate in

the Physical Rehabilitation

Project Charter

183

Advisory Committee. Ensure

overall LHIN objectives are

met throughout project

process.

Empower: Hold final

decision making say

throughout the project.

North West

Health

Alliance

Direct Neutral

Mod

High Moderate - Utilization of

resources in

project

management

-

Development

of central

intake system



data


development and


future state


information on similar

projects

Consult: Provide project

management support.

Involve: Provide insights to

represent best interests of

rehabilitative care across the

region.

Collaborate: Will actively

participate in decision making

process.

Project Charter

184

Change Management

Identify the amount of change that will result from the implementation of this project. Rate the expected amount of

change as Low, Medium, or High. Consider things such as: the breadth/scope of the project, the magnitude of the

change, the degree of automation that the implemented solution will result in, the amount of change required to

existing business processes, and the impact on individuals with regards to how they currently perform their jobs.

Amount of change expected: ☐ Low x Medium ☐ High

Identify the areas impacted by the change - both the people and structures of the affected organizations. Who will be

impacted, either positively or negatively, as a result of the change that will result from implementing this project? Are

there any security, legal or privacy implications that need to be considered? What will the project do to ensure end-

user/client uptake of the new product, service or solution?

Description of Impact Impact Management Strategies

List the change impacts this project will have on people

and organizations. Identify who/what will be impacted

and provide a description of that impact.

List the strategies that will be adopted on this project to

minimize the negative and maximize the positive change

impacts of this project.

- All rehabilitative care will utilize a common

referral form and a coordinated referral

management system

- Agreement by hospital CEO’s for global adoption

of a new system

- Involvement of allied health, physicians, CCAC

and utilization coordinators in referral form

development

- Utilization of NorthWest Health Alliance in

implementation of referral management system

- Adoption of common definitions for levels of

rehabilitative care

* Level of Involvement:

Educate/Inform (i.e. provide balanced and objective information to assist

with understanding the problem, alternatives, opportunities and/or

solutions)

Consult (i.e. obtain feedback on analysis, alternatives and/or decisions)

Involve (i.e. work directly throughout the project to ensure that concerns

and aspirations are consistently understood and considered)

Collaborate (i.e. partner in the decision process including the

development of alternatives and identification of preferred

solutions)

Empower (i.e. to allow final decision-making)

Project Charter

185

- Built-in regular evaluation metrics

- Potential redefinition of bed allocation and

outpatient/community program utilization

- Involve input from all organizations providing

rehabilitative care

- Ensure client needs are best met by any changes

- Follow best-practices guidelines for service

provisions

- Mitigate staffing changes and focus on resource

allocation within each location/service

- Designation of roles for each organization

within hub and spoke model

- Provide clear definitions of expectations for ; local

health hubs, district integrated networks and

rehabilitative care lead organization

- Outline how each level can collaborate to promote

integrated and close to home care

Procurements

Identify any procurements (e.g. project personnel, equipment, computer system) needed for the project.

Are procurements required? x Yes ☐ No If Yes, identify the type(s) of procurements needed.

Personnel:

- Dedicated project management support for the capacity planning, system re-design and implementation of an

integrated health system for rehabilitative care (1.0 Project manager position for 24 months)

- Dedicated technology support for the identification and implementation of a centralized referral system

(Support to be provided by the North West Health Alliance)

Equipment:

- Dedicated office, computer and telephone access for Project Manager

Computer System:

- In conjunction with CCAC, an electronic computer system to enable centralized referrals and ongoing

utilization support for all levels of rehabilitative care in the region. This will include an ongoing database of

Project Charter

186

available beds, staffing, and anticipated discharges across the region (inpatient, outpatient and community

programs).

Note: If Yes, the Procurement Plan is to be completed during the Planning phase of the project. Refer to PMO

template directory on SharePoint.

Community Engagement

Determine if any Community Engagement (CE) is needed for the project.

Note: CE is both a legislated responsibility and a core function of the LHINs. Local decision making is the model that

the LHINs are built on, and one that values the input of community members, health care professionals, and

stakeholders to inform our planning and decision making processes.

Is Community Engagement required? x Yes ☐ No

Note If Yes, the Community Engagement Plan is to be completed during the Planning phase of the project. Refer to

PMO template directory on SharePoint.

Project Risks

Consider what if… Document high-level project risks, apparent at this point, that could either positively or negatively

impact the achievement of project goals and objectives. Risks are uncertain events that may take place. Indicate the

risk, your response to manage it i.e. the Treatment and Response, the residual likelihood of it occurring, and its

anticipated residual impact. Focus on risks that are likely to happen and those that could have significant effect on

project success. Be sure to consider risks associated with people & organizational change, knowledge management,

and transition to operations.

Risk Treatment* Response Likelihood*

*

Impact**

*

Project Charter

187

List high-level risks i.e.

uncertain events that

pose threats or

opportunities to the

project.

Accept

Avoid

Mitigate

Transfer

Explain what will be done to accept, avoid,

mitigate or transfer the risk.

(Refer to

legend

below)

(Refer to

legend

below)

Not all stakeholders

agree on future state of

Rehabilitative Care

Mitigate - Involve representation of all

stakeholders throughout the project

- Utilize best practice guidelines to

support/facilitate recommendations

- Utilize Rehabilitative Care

Alliance decision making

frameworks to ensure objective

decision making

Likely Moderate

Not all organizations

willing to participate

Mitigate - Ensure commitment and support of

LHIN and CEO’s for full

participation

- Base recommendation on best

practices for client care

- Utilize available resources to

develop common definitions across

all organizations/levels of care

Possible Major

Insufficient financial

support to ensure success

of the project

Mitigate - Develop clear financial expectations

for the duration of the project

- Ensure ongoing communication

between LHIN and project leads

Unlikely Major

Capacity planning

exercise indicates need

for bed reductions

Mitigate - Evaluate entire system to identify

opportunities to offset potential bed

reductions (ie. alternate bed

allocations)

Possible Minor

Resource Matching and

Referral implementation

process not in alignment

with project

Mitigate - Continue to communicate with

MOHLTC and LHIN regarding

progression of RM&R

Possible Minor

Project Charter

188

- Include RM&R

recommendations/referral form into

post-acute review

Regional partners unable

to fully

implement/utilize

innovative models of

care to support from a

distance

Mitigate - Ensure ongoing communication with

regional partners

- Work with Ontario Telemedicine

Network to leverage existing

resources and technology

Possible Moderate

Health System Funding

Reform eliminates

portions of global budget

allocations and may

introduce uncertainty in

resources

Mitigate - Ensure ongoing communication

between MOHLTC, LHIN, and

hospital sites throughout the duration

of the project

Possible Moderate

North West CCAC

unable to meet the

referral management

needs

Mitigate - Utilize NorthWest Health Alliance

to support needs throughout the

project

- Allocate appropriate resources to

ongoing management and evaluation

strategies

- Develop support networks across the

region

Possible Moderate

System changes not fully

implemented at all sites

Mitigate - Garner support from Executive

levels and LHIN

- Identify best practices and base

recommendations on optimal client

care

Possible Major

Negative financial

impacts on an

organization through

changes in services

offered and funds

provided

Mitigate - Consider overall budgetary impacts

throughout process

- Identify alternate funding

opportunities to maintain financial

resources

Possible Moderate

Project Charter

189

Failure to recruit

sufficient human

resources to support

recommendations

Accept - Develop strategies to manage with

varying staffing availability within

the recommendations

Likely Minor

**Likelihood – The likelihood or probability that the risk/issue will occur.

Rare – Extremely unlikely. <2%

Unlikely– Could occur but unlikely. 10%

Possible – Might occur sometime. 25%

Likely – Will probably occur sometime. 50%

Almost Certain – Expected to occur in most circumstances. >75%

***Impact – The impact to the project the risk will have.

Insignificant – Can be dealt with or taken advantage of

easily/routinely.

Minor – Threat will threaten efficiency or effectiveness of some aspect

of the project but can be dealt with internally.

Moderate – Threat will significantly affect the project but not threaten

its survival.

Major – Threat could threaten the survival of the project as presently

defined.

Critical – Threat will almost certainly stop the project.

*Treatment – How you will manage the risk.

Accept – Acknowledge the risk and not take any action unless the risk occurs

Avoid – Eliminate the threat or protect the project from its impact

Mitigate – Reduce the probability of occurrence or impact

Transfer – Shift the impact of a threat to a third party along with the

ownership of the response e.g. buying insurance

Project Charter

190

Critical Success Factors

Define key factors that are critical to success of the project. These conditions must be satisfied to enable successful

completion of project objectives and deliverables. Include significant events or decisions that need to take place.

Successful development of guiding principles and adherence to principles by all organizations involved in the

review.

Full commitment and ongoing input from all stakeholders and support of CEO’s. This will be achieved through

advisory committee and working group involvement, and broad community forums as required.

Ongoing effective communication occurs to ensure engagement at all levels of care (front line providers, clients,

management, and administration) and across all stages of rehabilitative care (inpatient, outpatient, and

community).

Identification and development of an implementation plan for a system to manage all referrals and program

placement throughout the region.

Development of an evaluation system to monitor effectiveness and identify system breakdowns in order to

maintain ongoing utilization and commitment to system use.

Assumptions & Constraints

Assumptions are external factors that, at the time of writing the charter, are considered true, real or certain for

purposes of planning. Certain unverified or unknown aspects that are likely to happen must be assumed as facts to

proceed. Constraints are factors that are external to the project (i.e. outside the control of the project team), that

restrict or regulate the project. They limit available options and affect performance of the project e.g. an imposed

deadline, a specific budget, etc.

Assumptions Constraints

List the assumptions made to date. What did you

have to assume to be true to complete the charter?

List project constraints. Consider time, budget, scope, quality,

availability/skills of resources, priorities, etc.

All parties involved adhere to guiding

principles throughout the project

All organizations will commit to participate in

the capacity planning exercise in a timely

fashion

Continually changing staffing needs and care demands will

necessitate ongoing communication throughout the project

Limited data is available to inform certain areas of capacity

planning and may impact the overall results. This will

require some reliance on subjective data reporting creating

a risk of misrepresentation.

Project Charter

191

All rehabilitative care facilities/programs will

accept the recommendations and participate

fully in an integrated system

Sufficient resources are made available through

capacity planning, system development, and

recommendation phases

Full support of CCAC to increase role and

manage central intake of rehabilitative care

Availability of an appropriate electronic referral

management system that can accept referrals

and monitor ongoing program and staff

availabilities across the region

Time and resources are limited (all organizations may be

participating in several initiatives simultaneously and will

have competing demands due to internal operational

responsibilities).

Senior Team Representative

Sign-off by a member of Senior Team signifies that there is clear commitment on behalf of Senior Team to: provide

the necessary guidance and support, contribute necessary resources and budget, make decisions (approvals) and

resolve escalated issues in a timely manner, and, remove barriers to facilitate timely project completion, as outlined

in the charter. By approving the project charter, Senior Team has understood what will be delivered.

Name Signature Date

Project Sponsor

Sign-off by Project Sponsor signifies that there is clear accountability for the project by the sponsor, and a

commitment to: provide guidance and support, obtain necessary resources and budget, facilitate timely resolution of

escalated issues, ensure timely decisions are made and obtained, and confirm that all deliverables produced

contribute to achieving the project goals and objectives outlined in the charter. By approving the project charter,

Sign-Off

Project Charter must be approved & signed-off by the Project Manager, Project Sponsor and the North West

LHIN’s Senior Team before Planning can be begin. Once completed & signed-off, the charter forms the basis for

detailed planning and future decision-making. It cannot be modified without securing the sponsor’s approval and

possibly Senior Team’s approval. Any changes to information contained in the charter must be documented using a

formal Project Change Request and the associated process.

Project Charter

192

the sponsor has understood what will be delivered to achieve the identified business goals/benefits, and is in

agreement with the performance measures and success factors identified.

Name Signature Date

Project Manager

Sign-off by Project Manager signifies that there is clear commitment to adhere to the terms of the charter and

ensure that the project proceeds to meet the objectives defined in it.

Name Signature Date

Steering Committee Chair/Co-Chair [delete this section if not using a Steering Committee]

Sign-off by Steering Committee Chair/Co-Chair signifies that there is clear commitment to adhere to the terms of the

charter and to: provide guidance and support, obtain necessary resources and budget, facilitate timely resolution of

escalated issues, ensure timely decisions are made and obtained, and confirm that all deliverables produced

contribute to achieving the project goals and objectives outlined in the charter. By approving the project charter,

the Steering Committee members have understood what will be delivered to achieve the identified business goals/

benefits, and are in agreement with the performance measures and success factors identified.

Name Signature Date

Project Charter

193

Appendix E – Project Roles and Responsibilities

The following identifies the standardized project roles and responsibilities for North West LHIN projects.

Project Charter

194

Project Charter

195

Project Charter

196

Appendix F – Operationalization and Impact of RCA Deliverables

197

Appendix G – Methodology Quantitative Data Sources

Continuing Care Reporting System (CCRS),

National Rehabilitation Reporting System (NRS),

Cancer Care Ontario Access to Care reports,

Meditech Data,

Intellihealth Data collection system,

North West Health Alliance (NWHA) data collection systems,

Analysis provided by Preyra Solutions and the Central West LHIN.

198

Appendix H – Physical Rehabilitation Advisory Committee Rehabilitative Care Review

Guiding Principles

Guiding Principles:

Post-Acute Review - Physical Rehabilitation Advisory Committee 2015-16

1) The committee will share a common vision for creating an integrated rehabilitative care system

that is sustainable and meets the needs of consumers and families.

2) Discussions will begin from a position of trust: in preparation for the discussions, mutual

expectations will clearly be articulated. Members of the committee will work together to resolve

issues within the scope of the terms of reference (see attached).

3) Staff will readily share available data, information, knowledge, and wisdom to inform advisory

committee members so they may provide feedback and advice in the best interest of the

integrated rehabilitative care system as a whole. This will be conducted in a safe environment

for all members.

4) Members will work collaboratively, striving to reach optimal outcomes to meet the shared vision

of local health system planning including; equitable access for all as close to home as possible;

equitable access to appropriately resourced care regardless of ability to pay; a rehabilitative

care model with linkages between hospitals and community services supported by system-wide

support for access and navigation. Clinical best practices, metrics and standards will be utilized

and based on best available scientific evidence and updated as necessary by content expert

panels (eg. Orthopaedic review, Ontario Stroke Network, Quality Based Procedures, etc.).

5) Members will focus on achieving system wide transformations in the delivery of quality,

integrated patient-centered, sustainable rehabilitative care services.

6) Every rural region and community is unique in its history and development, and therefore in its

needs and aspirations.

7) The value of a service to the population must be considered to accurately assess performance of

rehabilitative care delivery in more sparsely populated rural areas.

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2015-16 PRAC Representation

NAME REPRESENTATION NOTES

Esme French (Chair) Public Representative Voting

Lauri Moffat-Zawacki Local Services Provider (BISNO) Voting

Jason Taddeo Local Services Provider (Family Physio) Voting

Dr. Hanan El Sherif Professional Staff Voting

Kathryn Hughes Local Services Provider (CCAC) Voting

Karen Pontello Local Services Provider Voting

Maria Lassonde Public Representative Voting

Stephen Mangoff (Vice Chair) Regional Hospital (East) Voting

Judy Mostow Public Representative Voting

Laura-Lee Barrie Local Hospital (TBRHSC) Voting

Lucy Venne-Fecho Regional Hospital (West) Voting

Sister Cecily Hewitt SJCG Board Representative Voting

Nancy Bouchard First Nation Representative Voting

Jocelyn Bourgoin

Angie Bishop

Susan Pilatzke

Heather Gray

STAFF RESOURCES

Kathleen Lynch VP, Rehabilitative Care & Chronic Disease Management Non-voting

Janine Black Director, Inpatient Complex Care & Rehabilitative Care Non-Voting

Susan Franchi Director, Outpatient Rehabilitative Care & Chronic Disease

Management

Non-Voting

John Clack Post-Acute Review Coordinator Non-Voting

200

ST. JOSEPH’S CARE GROUP

THUNDER BAY, ON

APPROVED: SEPTEMBER 2014

PHYSICAL REHABILITATION ADVISORY COMMITTEE

TERMS OF REFERENCE

MISSION STATEMENT

St. Joseph’s Care Group is a Catholic organization that identifies and responds to the unmet needs of the

people of Northwestern Ontario, as a way of continuing the healing mission of Jesus in the tradition of the

Sisters of St. Joseph of Sault Ste. Marie.

VISION STATEMENT

A leader in client-centred care.

PREAMBLE

Rehabilitation is a dynamic, goal-oriented, time-limited process which allows an individual with

impairment to identify and reach his/her optimal mental, physical, cognitive and social levels.

201

Rehabilitation provides opportunities for the individual, the family and the community to accommodate a

limitation or loss of function and aims to facilitate social integration and independence.8

St. Joseph's Care Group is committed to high quality rehabilitation programs and services that meet the

needs of individuals and their families within the region of Northwestern Ontario. Interdisciplinary teams

of care providers work with clients and families within a variety of inpatient and outpatient programs.

PURPOSE OF THE ADVISORY COMMITTEE

The Advisory Committee for Physical Rehabilitation Services is established by the Board of Directors of

St. Joseph’s Care Group to provide advice regarding the Rehabilitation programs and services within the

Hospital. The primary responsibilities of this advisory committee are as follows:

1. To make recommendations to the Board of Directors regarding policy issues related to the

rehabilitation programs.

2. To assist with the development and maintenance of co-operative relationships with other agencies

providing rehabilitation services in the community and region.

3. To advise the Board of Directors of needs and concerns to which the rehabilitation programs

should respond.

4. To participate in the development and ongoing evaluation of the programs and make

recommendations for the achievement of the program objectives.

COMMITTEE MEMBERSHIP:

8Ministry of Health, Rehabilitation Strategy, 1993; Adapted from the World Health Organization.

202

1. The Committee will consist of representatives from a variety of identified key stakeholder groups

from the community and region.

2. Membership on the Committee will reflect the makeup of our community.

3. The Committee will consist of 14 members from the community and region and one member

representing Care Group Administration. Representation shall be as follows:

four (4) representatives from local service providers

one (1) representative from Thunder Bay Regional Health Sciences Centre

two (2) representatives from regional hospitals or service providers (1 representative

from the east and 1 representative from the west)

one (1) member of the Professional Staff

three (3) public representatives

one (1) representative from the First Nations

one (1) representative from the Board of Directors, St. Joseph’s Care Group

one (1) representative from Administration, St. Joseph’s Care Group (non-voting)

4. Participation will be on a voluntary basis and the term of service will be a renewable three year

term. Members may be re-nominated, but may only serve three consecutive three year terms.

5. The Advisory Committee will make recommendations to the Board of Directors of St. Joseph's

Care Group for its own replacements.

6. The Chairperson and the Vice-chairperson will be selected by the Advisory Committee and will

serve a one year renewable term. The Vice-chairperson will become the Chairperson subsequent to

the completion of the Chairperson's term. No Committee member may serve as Chairperson or

Vice-chairperson for more than three (3) consecutive annual terms in one office; however,

203

following a break of at least one annual term in the continuous service, the same person may be re-

elected in either office.

7. Every effort will be made to rotate up to 25% of the membership each year.

8. Each Committee member should attend at least 75% of the scheduled meetings.

9. When a member resigns his or her seat on the Committee, or is unable to complete the term for any

reason, then the Committee shall decide whether to fill the vacancy or leave the position vacant

until the beginning of the next calendar year.

MEETINGS

The Advisory Committee for Physical Rehabilitation Services shall meet a minimum of four times a year,

with additional meetings as required. In June, the dates and time for the meetings will be established for the

entire year. The Care Group will provide the secretarial support for the year.

QUORUM

There shall be a requirement of a minimum for fifty percent (50%) plus one attendance to constitute a

working quorum.

204

VOTING

There shall be a requirement of a minimum of fifty percent (50%) plus one favourable vote of those member

representatives in attendance to resolve or approve any issue requiring a vote.

In the development and/or research of issues to be discussed, the Advisory Committee may establish a

format and structure to ensure appropriate input. In addition, program staff and other identified "experts"

may be requested by the membership to comment on issues as the need arises, to assist members in

providing an informed vote. Guests may be invited to meetings with the prior approval of the chairperson.

AGENDA

The agenda will be developed by the Chairperson and program staff and by specific request from committee

members. Every effort will be made to have all material in the hands of the committee members no later

than one week prior to the meeting.

ORIENTATION

All new committee members will receive an orientation to the committee. This is the responsibility of the

Chairperson and program staff. Ongoing orientation and continuing education for committee members will

be provided as needed.

AD HOC COMMITTEES

Ad hoc committees should be formed to deal with one time issues, have a limited time span, and can draw

on any number of persons who are experts, have interest in, or are neutral to but knowledgeable of the issue.

This type of committee is to report to the Advisory Committee for Physical Rehabilitation Services on

205

findings and recommendations, in order that the Advisory Committee for Physical Rehabilitation Services

can conduct a factual discussion and subsequent vote on the issue.

ONGOING COMMITTEES

Ongoing committees should be formed for the purpose of planning, implementing, monitoring, co-

ordinating, evaluating and maintaining a regionally designated or agreed programs and services, and

reporting on progress and related matters to the Advisory Committee for Physical Rehabilitation Services

at prescribed intervals. Such a committee should function as an advisory and information body to the

Advisory Committee for Physical Rehabilitation Services.

Recommended to the Board of Directors: September 20, 2012

206

Appendix I – Community Engagement Stakeholders

Atikokan General Hospital- rehabilitation providers, manager, and clients/families

Dryden Regional Hospital- rehabilitation providers, manager, and clients/families

Geraldton District Hospital- rehabilitation providers, manager, and clients/families

Lake of the Woods District Hospital- rehabilitation providers, manager, and clients/families

La Verendrye Hospital- rehabilitation providers, managers, and clients/families

Manitouwadge General Hospital- rehabilitation provider

Margaret Cochenour Memorial Hospital- rehabilitation providers

McCausland Hospital- rehabilitation providers, clients/families

Nipigon Memorial District Hospital- rehabilitation providers

Sioux Lookout Meno Ya Win Health Centre- rehabilitation providers, manager

St. Joseph's Hospital- rehabilitation providers, managers, and clients/families

Wilson Memorial General Hospital- rehabilitation providers, clients/families

Bayshore Therapy and Rehab

North West CCAC

Partners in Rehabilitation

Aboriginal Advisors North West LHIN

Chiefs of Ontario

Dilico

Home and Community Care Program, Ontario Region; First Nation Inuit Health Branch Health

Canada

Public Health Unit, Ontario Region; First Nation Inuit Health Branch Health Canada

Le Réseau du mieux-être francophone du Nord de l’Ontario

207

Appendix J – RCA Bedded Levels of Rehabilitative Care Mapping Tool

208

Appendix K – RCA Community-Based Levels of Rehabilitative Care Mapping Tool

209

Appendix L – System Strengths and Gaps

System Strengths

Theme Relevant Quotes, Anecdotal Stories

There is good client experience and appropriate level of care at the right place and the right time

-Quality of Care -Access to services locally

-Staff were always professional, kind and exceptionally knowledgeable -“Staff truly cared about my dad and his progress” -“The nursing staff is really good and have more time to spend with clients” -“I loved that staff always encourage family participation. It allowed us to see exactly how exercises are to be done” -Clients identified the importance and need for good self management skills and taking ownership of their own follow-up and appointments; they even suggested public marketing campaign to strengthen this -“It is so nice having someone locally. The fly in-fly out model of care didn’t work well for our clients.” -“Despite what the Ministry of Health says, outpatient services within the hospital are NOT inefficient and home care is not always the best use of resources” -Clients are appreciative of the ability to access ongoing OP therapy locally especially physiotherapy -Clients from Northern communities are able to access home care services in Dryden while staying in a hotel before they return home -Access locally to “tertiary wound team” with nursing, chiropody and surgeon but only rehab as required (Kenora, Fort Frances) with good knowledge and clinical skills, easier to implement locally but don’t always have the bed availability -“I feel that we are able to manage the clients with hip fractures locally as long as they are able to manage with physiotherapy once a day and nursing care once a day, anything more intensive we appreciate sending to Thunder Bay.” -Geriatric rehabilitation or Assess and Restore is manageable at IDN and LHH level although in some facilities lack of SW or OT limit the ability to provide this care -Therapists do it all- inpatient, outpatient and home care but feel pulled in many directions and service providers are concerned that the elderly, indigenous, and marginalized populations may fall through the cracks -Through CMHA there is a Geriatric mental health worker for standard cognitive assessments and behaviour intervention in Sioux Lookout Older Adult program and Geriatric Behavioural Specialist in Dryden Older Adults Program

210


-Infrastructure to support Indigenous culturally appropriate care in Sioux Lookout

-Clients are appreciative of local physiotherapy services and identify local OP OT and SLP resources as a gap -Creative partnerships for funding shared position has resulted in more services locally including: OT with Dryden FHT and hospital, OT with Firefly and Red Lake Hospital, SLP with Meno Ya Win and Dryden Hospital -The Sioux Lookout Meno Ya Win hospital has excellent infrastructure in place to provide culturally appropriate care for indigenous population such as on site hostel, healing rooms, interpreters -Due to the proximity and access to resources, families/escorts are able to come to Sioux Lookout for teaching two days prior to discharge home

Access to specialized services regionally is invaluable

-Neurology services

-“Without the physiotherapy that Dad received at St. Joseph’s Hospital, Neuro Day and continues to receive in Kenora, he wouldn’t have the quality of life that he does and the movement and progress he has an continue to make” -“We appreciated the option to continue in Neuro Day at a more frequent intensity that was available in our own community” -“It was nice to know a physiatrist was just a phone call away “ -Specialized wheelchair prescription and training is provided appropriately in Thunder Bay -Specialized stroke rehabilitation is provided appropriately in Thunder Bay due to interprofessional team, intensity, knowledge and skills

There is smooth transitions and communication along the continuum of care

-Electronic Medical Record infrastructure -Connections with other rehabilitation professionals in NWO -Integration of CCAC services within hospital infrastructure

-The common electronic medical record throughout NWO makes information and communication much easier, this is very apparent when there are clients who have had care elsewhere in Sudbury, Sault Ste. Marie or Manitoba -“It is always easier to call and communicate with the next care provider when I already know them as a person” -Having a contact list of other rehabilitation providers through NOSM was great but difficult to keep updated, it would be beneficial to have added areas of specialty included -Formal meetings with other therapists and managers in the West and the North Shore group in the east are very valued but “there is a disconnect between Thunder Bay and the region.” -Communication with the CCAC provider locally is smooth as we are so small we know each other well -Hospital having CCAC contract in the region makes client transitions easier, seamless, and more appropriate and more efficient with the added benefit of accessing the shared EMR -Clients in a small community noted that when there are personality differences, they have no choice, it is the same therapist for inpatients, outpatients and home care -Where this isn’t in place, it was suggested there be better communication with local SW when CCAC contract providers will be in town -Integration of FHT and CCAC nursing in Manitouwadge is working well

211


Use of technology to access services close to home

-Cardiac Rehabilitation/ Healthy Lifestyles -Moving on after Stroke -Rheumatology Services -Psychiatry services -OP Physiotherapy Services -Nursing

-The cardiac rehabilitation model works really well with frequent communication to specialists in Thunder Bay; cardiac rehab is sometimes limited for people on shift work; one client noted that he had a 9 month wait to get his stress test for cardiac rehab and another month to actually get started on the program from a rural site; -Other facilities noted this is a gap and clients are repatriated with NO cardiology follow up or referral to cardiac rehab- some facilities have started their own programming locally -Service providers suggest similar systems to cardiac rehab for pulmonary rehab -Great to have access to this and it worked well but not timely -Access to Rheumatologist via telehealth is great but a refresher on assisting with joint counts would be good; “works really well for patients that get in!” -Coordination with local resources is necessary as impacts ie. OT in Geraldton -Recent access to visiting specialist Dr. Aubrey in Kenora -Access to psychiatry services working well but service providers locally need to remember there is access -Provision of initial assessment and self management initial treatment for physiotherapy in Ignace, could be expanded to other areas ie. Nipigon to Beardmore -good use of CCAC Diabetes and BP phone call and telegeriatric nursing

Evidence based care, client centered care

-Family Health Teams -The Family Health Team in Dryden supports return to driving screening assessments and triaging for their clients by providing OT resource within FHT model -FHTs are providing exercise opportunities (Zumba, nordic pole walking, walk and talk and resistance bands) in some communities targeting clients with Diabetes, high risk factors for stroke, and cardiac issues -FHTs providing Chronic disease self management 6 week program and pre-op behavior changes such as weight loss and smoking cessation

System Gaps

Theme Suggestions, Relevant Quotes, Anecdotal Stories

The client experience is limited by geographical distance

-Preferred location -Access to temporary accommodations

-Thunder Bay is so far away- families and clients often would rather go to Winnipeg for services such as prosthetics -“I wished could have been home sooner” -Temporary accommodations similar to Tamarack house for Cancer patients or better hospital rates at hotels in Thunder Bay would be beneficial -Provide a list of housing and hotel options with kitchenettes for regional families

212


-NIHB medical travel policies

-Having family in Thunder Bay makes it manageable for many -NIHB medical transportation policies limits service to many Indigenous clients to Neuro Day; there is very inconsistent approval and ability to extend stay beyond 4 weeks

Clients are lacking appropriate level of care at the right place and the right time

-Inpatient Occupational Therapy -Inpatient SLP services -Outpatient OT services -Nursing culture -Use of support personnel in rehab -Social Supports -Medical Equipment:

-The lack of OT inpatient services was noted in hospitals in the District of Thunder Bay (except Geraldton) and would assist with home visits, discharge assessments and cognitive assessments and treatments and support the ability to provide Assess and Restore interventions and driving screens -Without a local SLP, facilities needing a swallowing assessment for inpatients need to refer to the next level of health service (ie. IDN) -“In a perfect world there would be outpatient OT services within the hospital like there is physio” -This would assist in earlier discharge and decreased LOS -There is a large gap in cognitive, community reintegration, and arm and hand interventions as CCAC OT services focus on home safety and equipment -Integration with the FHT in Dryden has allowed for access to OP OT services with good results -There is no “rehab culture” in the nursing departments of small hospitals and as a result rehab staff continue to provide care that is defined by RCA to be delivered by nursing or non-regulated providers; this is due to the shared roles for many nurses who are the charge nurses, the discharge planners and the chemotherapy nurse at the same time - There are many new grad nurses in rural hospitals with minimal skill experience -“There would need to be a cultural shift- historically our hospital uses professional staff rather than support -personnel” but this would support alignment with use of regulated professionals -There may be some possibilities using rehab assistant model to support OT services in smaller LHHs -There is an identified need for more supportive housing options throughout the North West LHIN -There is limited ongoing social support programs in many of the local health hubs for people still in their own homes such as communal dining, accessible public transportation, ongoing exercise classes resulting in premature need for LTC -There needs to be homemaking after 6 pm and more accessibility on weekends in the small communities -Identified need for ongoing social support for people with stroke following OP and MOST in the region like Stroke Recovery Network in Thunder Bay -“The system doesn’t currently account for the profound sense of loneliness in the ‘home first’ program” -Loan equipment is not available at all hospitals and there are not local rentals available in all LHH; this equipment is difficult to track and maintain -Anticipated equipment needs in advance of transitions and advance of home visits are helpful

213


-Delivery and servicing of equipment twice a week (some only every 7 weeks) to LHH is limiting especially with recent changes in vendor -Strong relationships with vendors is helpful -Most vendors won’t provide rental equipment to northern communities or other First Nation communities such as Aroland who aren’t serviced by CCAC; although they can rent while staying in Thunder Bay or Dryden -Pediatric equipment availability is very limited in LHHs -Clients need to come to LHH with appropriate braces as there is nothing locally even while waiting for custom

Accessibility to specialized inpatient rehabilitation is limited and criteria for program admission would benefit from clarification [from service providers]

-Wound Beds -Inpatient admission to SJH -Weekend therapy

-“There are never any wound beds available” -Acceptance decisions are made with little explanation just “she doesn’t qualify” -It would be nice to talk to the other therapist directly and explain the situation and recommendation for access to regional rehabilitation bed -Many service providers were unaware of potential for direct access to specialized senior rehab to avoid readmissions and felt this would be appropriate and the Family Health Team would be a good referral source, in some cases in the District of Thunder Bay referrals were denied admission; the perception is that if someone is ambulatory, they don’t get in -Sometimes local physicians are a barrier if things didn’t go well for another client, they won’t refer again -The process for referring to inpatient programming needs to be clarified (?STRATA referral rather that physician to physician contact) -Limited access to therapy on the weekend -“Weekends were long. There needs to be more staff”

There are identified gaps in Specialized outpatient services

-Chronic Pain services -Geriatric/Psychogeriatric and Wound Care services

-Access to Chronic pain programming in Thunder Bay is identified as a gap and sites have started to use 6 week chronic disease management program for these clients at the local FHT -“Hub and Spoke? Feels more like a desert island. If you can swim to us you can stay but most can’t get to the island!” regarding physical access, need to be well enough to stay in Thunder Bay for 6 weeks on own but not too well that you aren’t already back to work as then it is difficult to access a 6 week program; have started a 2-3 day program; there is also potential to work with LHHs to develop their own programs with support; there is potential to VC exercise/movement session to the region and do follow up through PCVC -It is difficult to establish connections for ongoing programming using Hub and Spoke Model with staff turnover in the region. It takes time to develop relationships and find a champion -Consultations are provided but not implemented [wound care; geriatric services] -Access to psychogeriatric services are not timely *accessing Dr. Conn? From Baycrest in Sioux Lookout; suggested that psychogeriatric assessment should be in person first and follow up via telehealth

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-Driving Assessment -VON community exercise classes

-The process for return to driving assessment is lengthy and expensive for many clients and it is a barrier to get to Thunder Bay due to transportation; It would be helpful to have some training on the screening process and triaging so this can be done locally and to ensure that we are only sending appropriate clients for full assessment -Service providers identify successful VON exercise classes as a gap including suggestions for better integration with physiotherapy departments, better marketing throughout NOW, and better availability in remote northern communities; in Dryden, community integration to classes done by CCAC physiotherapists (hospital staff)

There is room for improvement at times of transitions with communication to discuss the local ability to meet the needs of the client

-Documentation -Opportunities for communication pre- transitions

-Improved documentation for WB orders, ROM, precautions and equipment needs, status of equipment prescription; a discharge checklist or 1 DC sheet would be ideal -It is difficult to find physio notes in EMR especially the day to day treatment activities and client home programs -Thorough, timely discharge assessments are not always evident and would help with transitions -It certainly would be better to have a phone call or a videoconference (if there are visual benefits such as transfers, walking) prior to discharge especially if the situation is complicated, there are cognitive concerns or to help interpret cognitive screens and to explain any outstanding equipment, teaching, etc. Knowing this in advance will decrease misunderstandings on admission to local hospital -It would be beneficial to be part of the family conference especially if there are concerns with the family or CCAC needs, this could be determined at time of initial therapist to therapist phone call -“The transition from inpatient services to home with outpatient services was very poorly coordinated and communicated. The family conference was basically to tell us when we would be going home. Staff in Thunder Bay was unaware of local services in Emo for physiotherapy but suggested OP services in Fort Frances due to availability of OT there. Unfortunately the OP OT had a waiting list of months so starting physio in Emo would have been better. In fact, at the time the staff offered for us to stay in Thunder Bay and access Neuro Day services, we refused, as we just wanted to get home. But if we had realized it would be four months, we would have stayed. If the therapists communicated with one another at the time of planning, or staff in Fort Frances were part of the family conference, this would all have not been an issue.” *of note, other clients felt that communication between staff was good -“There is minimal cognitive assessments but life-altering recommendations [such as 24 hour supervision]” -A phone call would clarify the ability to meet the client needs locally ie. Specialized splinting post hand surgery; availability of rental equipment, therapist vacation etc. -Communication pre-discharge with local Home and Community Care programs (FN communities) is essential -Having CCAC or community coordinator at rounds is essential -“It is hit and miss that I am aware of someone getting a knee replacement before they return from their surgery. I usually am made aware on Day 4 post-op”

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-Timeliness of referral for elective surgery

-I don’t know if my clients get pre-op teaching in Thunder Bay for TKR; -it was suggested that telehealth be used for group pre-op teaching or even to be done locally if feasible -Client indicated he was very pleased with process of getting exercises and education re: supports needed at home and measurement of medical equipment, and booking initial post op physio appt in advance all accessed locally BUT he was told to do this by a friend who had surgery, never was this set up by healthcare system

There are identified gaps in access and process for OT Home Visits across the region

-If OT available in the hospital and there is a high risk discharge, OT in hospital will do the visit (Dryden, Geraldton) -At SJH, home visits are done routinely unless there is no concerns with client safety or family -The process for home visits through CCAC needs to be clarified as it varies from site to site -If safety is a concern, it should be feasible for clients to go out on a pass with the OT from CCAC and stay home if all is safe; but transportation is sometimes a barrier to get to the home visit as this isn’t covered and not everyone has family -If there will be renovations needed or equipment to wait for, some facilities will do home visits without the client and use photos of the house, others will do the home visit with the client and they may need to return to the hospital to await renovations or specialized equipment; this is particularly a concern in smaller centres like Ignace or Rossport accessing from hospitals in Dryden or Terrace Bay -Sometimes clients aren’t able to access OT home safety visit until they are discharged which feels like: “teaching someone to swim on land but not providing them with water wings until we throw them in the pool to see if they drown”; one client indicated that he was discharged right home without anyone assessing his ability to do stairs- he had to bum up them! -OT CCAC services in the District of Thunder Bay are usually only available every 3-4 weeks due to service provision by a company in Thunder Bay; in Sioux Lookout available within a week; -“My home visit occurred a week after I had already been home!” -No home visit assessment available in Northern reserves of Northern IDN, will often have Home and Community Care staff trial equipment in the house to see if it fits and is appropriate before the client returns home, families provide measurements and photos of the home -Having a 3 day “progressive discharge” is helpful for client transitions home -It was suggested that CCAC home visit could be initiated in Thunder Bay

Clients and families require more support at times of transitions

-“Every transition is freaky! They don’t give you a choice. I was overwhelmed and it happened so fast” -A navigator would be been beneficial; “I have spent many hours in attempts to find an agency who can guide the stroke survivors through application for some form of income when their benefits are exhausted. Sadly, even once connected to a department, which can direct them to their next course of action, unless some accompanies

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along the continuum of care

them to their appointment, they frequently misunderstand or forget most of what they have been told…. What these clients need is a case manager or client advocate who can accompany them on this rather daunting journey.” This was also noted for wound care clients -“We were missing the player to check in on how the family was doing” -5 of the 11 hospitals do not have a Social Worker: there is some positive experiences sharing SW resources with FHTs

There are knowledge and skill training needs to provide evidence based care and client centered care

-Having an annual retreat for education, updates and networking would be good but it is more important to have timely, immediate access to a resource person -The Community of Practice model doesn’t work for everyone, it is more needed in the region but there is little incentive for therapists in Thunder Bay to participate as they have access to one another locally -Smaller professions such as the dietitians and SLPs have a regular email group to contact one another -The knowledge and skills of some local CCAC providers is limited for adult rehab as they mostly serve pediatric clients -Having access to resource people is necessary and having one “regional lead” would be easier to contact -More rehabilitation training for LHH level PSWs would be beneficial for CCAC services and Home and Community Care services -Arranging for PSW training in CCAC difficulty -There is a loss of rehabilitation education at the graduate level locally in NWO, through partnerships with NOSM and McMaster which will potentially impact recruitment and retention

Hospital Funding Systems

“As long as we are globally funded, rehabilitation will always be threatened in a general hospital. We need to have dedicated and protected budgets for rehabilitation, OT, PT and Speech services.” -“Unless home care is aligned with this model [integrated rehab model] this won’t work!”

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Appendix M – Regional Population breakdowns by IDN:

City of Thunder Bay IDN:

The City of Thunder Bay IDN is comprised of one Local Health Hub serving twelve communities and a

total population of 127,975. This IDN accounts for 55.3% of the North West LHIN’s population over a

geographic area of 37,100 square KM. The median age of residents within the City of Thunder Bay is 44

years of age. Additionally, 17.2% of residents in the District of the City of Thunder Bay are over 65 years

of age. There are 26 unique health service providers offering 41 LHIN funded programs within this

district. Additionally, there are two primary hospital facilities within the City of Thunder Bay IDN;

Thunder Bay Regional Health Sciences Centre (Tertiary) and St. Joseph’s Hospital (Post-Acute Care).

District of Kenora IDN:

The District of Kenora is comprised of three Local Health Hubs, Kenora, Dryden, and Red Lake that

serve 21 communities. The population of the District of Kenora IDN is 43,133 representing the second

largest IDN in the North West LHIN (18.7% of the total population). The Kenora IDN has an

approximate total area of 54,108 square Km with 53.5% of the population living in rural areas.

Approximately one-quarter of the population in this district self-identify as Indigenous. Within the

District of Kenora IDN there are three primary health care facilities; Dryden Regional Health Centre

(Dryden), Lake of the Woods District Hospital (Kenora), and Red Lake Margaret Cochenour Memorial

Hospital (Red Lake). In addition, the District of Kenora IDN has 37 unique health service providers

offering 51 LHIN funded programs. Due to their proximity to Manitoba, clients in the District of Kenora

IDN often seek complex/tertiary medical services in Winnipeg as opposed to travelling to Thunder Bay

in order to remain close to home.

District of Rainy River IDN:

The District of Rainy River IDN is comprised of four local health hubs, Rainy River, Fort Frances, Emo,

and Atikokan that serve 19 communities. This IDN is the fourth most populated district in the North

West LHIN with a total population of 20,370 accounting for approximately 8.8% of the total LHIN

population. The District of Rainy River IDN has an approximate total area of 15,474 square Km and

21.8% of the population lives in rural areas. In addition, the District of Rainy River IDN is home to the

greatest proportion of adults over the age of sixty-five, comprising approximately 20.5% of the districts

population. Within The district of Rainy River IDN, there are 19 unique health service providers offering

31 LHIN funded programs. The primary care facilities include LaVerendrye Hospital (Fort Frances) and

Atikokan General Hospital (Atikokan) with additional health centers in Rainy River and Emo.

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District of Thunder Bay IDN:

The District of Thunder Bay is comprised of five local health hubs in Greenstone, Manitouwadge,

Terrace Bay, Nipigon and Marathon. These health hubs serve a total of 17 communities across the

approximately 61,215 square Km in this region. The total population of the District of Thunder Bay IDN

is 17,829 (7.7% of the North West LHIN population) with 43.7% living in rural areas. In this IDN, 10.5%

of residents identify as Francophone with the greatest proportion residing in Greenstone. There are five

hospitals in the District of Thunder Bay including Geraldton District hospital (Greenstone),

Manitouwadge General Hospital (Manitouwadge), Wilson Memorial General Hospital (Marathon), The

McCausland Hospital (Terrace Bay), and Nipigon District Memorial Hospital (Nipigon). Additionally,

within this district there are 21 unique health service providers offering 20 LHIN funded programs.

Northern IDN:

The Northern IDN is comprised of one Local Health Hub (Sioux Lookout) serving 28 communities

across an approximate total area of 290,859 square KM. The Northern IDN accounts for 9.4% of the total

population of the North West LHIN. Within the district, 76.9% of the population lives in rural areas and

81.3% of the population self-identify as Aboriginal. Within the Northern IDN, a unique population trend

has been observed 40.61% of the population is aged 0-19 and only 5.91% of the population is over the

age of 65. This represents a significantly different population distribution as compared to the North West

LHIN as a whole. The health care needs of the Northern IDN are served by one primary health care

facility (Meno Ya Win Health Center) in Sioux Lookout. In addition, there are 40 unique health care

providers offering 47 LHIN funded programs.

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Appendix M – Current Estimated Beds

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Appendix N – Hip Fracture Process Map

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Appendix O – North Western Ontario Community Physiotherapy Referral Decision Tree

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Appendix P – Rehabilitation Resources in the North West LHIN

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Appendix Q – Geriatric Assessment & Rehabilitative Care Stream

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Appendix R – Stroke/Neuro Care Stream

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Appendix S – Musculoskeletal Care Stream

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Appendix T – Medically Complex Care Stream

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