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Implementation of a Care Stream Model Supporting an Integrated Regional Rehabilitation System Across the Continuum of Care

June 2, 2017

Presented by: Susan Franchi, St. Joseph’s Care Group Denise Taylor, St. Joseph’s Care Group

Presentation prepared by: Kathleen Lynch, Vice President Rehabilitative Care and Chronic Disease Management Janine Black, Director Inpatient Complex Care and Rehabilitative Care Susan Franchi, Director (Presenter) Outpatient Rehabilitative Care and Chronic Disease Management Denise Taylor, Coordinator (Presenter) Rehabilitation Review St. Joseph’s Care Group John Clack, Manager Medically Complex Services

Supported by:

About Us

St. Joseph’s Care Group is a Catholic organization

that identifies and responds to the unmet needs of

the people of Northwestern Ontario

Core Service areas include: Addictions & Mental

Health, Rehabilitative Care & Chronic Disease

Management and Seniors’ Health

Programs and services are provided throughout

the community and at nine different sites

Our Care Stream Vision

An integrated rehabilitation system across the full continuum of care:

Inpatient/outpatient community where individuals receive client-centred culturally- safe care from an interprofessional team as close to home as possible

4

8

CCC

20 8

7

7

13 12

174

Rehabilitation

50

4

9

Convalescent Care

10

Current State

Creation of a Care Stream Model

Client referrals to St. Joseph’s Care Group Programs and Service are accepted from all levels of care

Thunder Bay Regional Health Sciences Centre

Regional Healthcare Facility

Community or Primary Care

Care Stream Model Supports:

Evidence-based care (Practice level)

QBP adherence (Practice level)

Standardization (System level)

Improved access and transitions (Practice level)

Effective use of resources (Organizational level)

Clinical Lead Physician Specialist

Inter-professional Team For Triage

Assessment Treatment

Regional Providers

Regional Providers

Regional Providers

QUALITY CARE COLLABORATION EDUCATION

INPATIENT OUTPATIENT COMMUNITY

Outpatient Role

Designed to:

Prevent clients from entering the hospital system

Ensure clients have access to appropriate outpatient services so they can return home

Examples

Frail Seniors’ Pathway from the ED with Rapid Response to interprofessional geriatric assessment

Inpatient to outpatient neurology services

– smooth transfer

– telemedicine speech-language pathology

The Care Stream Model:

Provides the right care, at the right time, in the right place

– As close to home as possible

Provides access to rehabilitation which optimizes function

Organizes the continuum throughout the region

The Care Stream Model:

Provides opportunities to work with regional partners

Standardizes definitions and performance metrics

Streamlines referrals

Findings

Need for a regional network for clinician communication, education, and skill development

Need for capacity building throughout our region including physician specialists (rheumatology, geriatric psychiatry, physiatry)

Summary

Next Steps: Implementation and Evaluation

Preventative Opportunities

Reactive

Questions?

Denise Taylor taylord@tbh.net

Susan Franchi franchis@tbh.net