central east lhin musculoskeletal rehab plan/media/sites/ce/uploadedfiles/... · 2014-07-23 ·...

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Central East LHIN Musculoskeletal Rehab Plan

http://www.community-care.on.ca/

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Executive Summary ............................................................................................................................... 3

Introduction ......................................................................................................................................... 5

The Planning Process ......................................................................................................................... 6

Values.............................................................................................................................................. 7

Current Context .................................................................................................................................... 9

Health System Reform........................................................................................................................ 9

Demographics and Demand for Musculoskeletal Rehab ........................................................................ 13

Current State of Rehab Services in the Central East LHIN ....................................................................... 15

Rehab Services Recommendations......................................................................................................... 32

Aligning Care to Patient Need............................................................................................................ 32

Trauma and Non-Elective Patients ..................................................................................................... 34

Process Reviews and Quality Improvements ........................................................................................ 36

Setting Standards ............................................................................................................................ 38

Promoting Ongoing Quality Improvement and Innovation ..................................................................... 44

Improving Data Collection and Performance Monitoring ....................................................................... 46

Enhancing Preventative Care ............................................................................................................. 48

Implementation .................................................................................................................................. 50

Conclusion ......................................................................................................................................... 54

Appendices ........................................................................................................................................ 55

Appendix A: Rehab Service Task Group Membership ............................................................................ 55

Appendix B: CMGs included in “Orthopaedic Care”............................................................................... 56

Appendix C: Outpatient Volumes 2012/2013 ....................................................................................... 58

Appendix D: GTA Rehab Network Patient Flow Maps ............................................................................ 61

Appendix E: National Hip Fracture Toolkit Exert ................................................................................... 63

Appendix F: References .................................................................................................................... 64

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Executive Summary Members of the Rehab Services Task Group (RSTG) have developed a set of recommendations that seek to improve the quality of care, patient access and experience, and value-for-money in rehabilitative services. The goal of the RSTG was to create a vision for a regionally coordinated program that adheres to the following values:

• Equitable access • Services for priority and marginalized populations • Regional, cluster or local service models to promote access, efficiency and clinical competence • Standardization for quality outcomes • Optimal patient flow • Maximizing health human resources • Innovations for continuous improvement • Appropriateness of rehab modalities • Focus on prevention • Rehabilitation starts pre-operatively

Like much of health system reform the ultimate impetus for this planning exercise is the growing and aging population in Ontario. As the population ages, demand for healthcare will increase. This will be felt particularly in sectors, such as rehab, that support complex patients. The Central East LHIN will be especially pressured by the aging population because the age of the population in the Central East LHIN is increasing at a faster rate than the provincial average and because investment in the Central East LHIN has been focused on acute care beds – rather than less expensive rehabilitative beds that are often more appropriate for the needs of complex seniors with high needs. Rehabilitation services are provided across the continuum of care. Patients may receive rehab within the hospital sector, either in an inpatient rehab bed, a complex continuing care bed or an acute care bed. Hospitals also offer rehab services on an outpatient basis. Currently, other patients receive publicly funded care through OHIP funded physiotherapy clinics. Rehab is also provided by the CCAC in patients’ homes for those who cannot access outpatient care or clinics. Rehab professionals also work within Long-term Care Homes and these services are currently funded by OHIP. Those that can afford it may also obtain rehab privately. In the Central East LHIN rehab services are currently provided in each of these settings depending on patients’ clinical needs, their personal circumstances and where they live. The widespread use of innovative practices such as a co-managed medical models, quality improvement initiatives, senior’s friendly programming and patient education have enhanced the efficiency and quality of rehabilitative care in these settings. Despite continued efforts to improve rehabilitative care and capacity, the system faces a number of pressures. Data collection is limited and lacks standardization, thus understanding current demand and patients’ care across the continuum of care is challenging. Bed utilization is not optimal within hospitals due to fiscal constraints and this impacts the availability of rehabilitative care. While the quality of care provided in the Central East LHIN is high, best practices are not always met. In particular, 7-day a week physiotherapy is an evidenced best practices that is not provided because of a variety of human resources models, recruitment challenges and competition for dollars. There is a dearth of outpatient physiotherapy in the North East Cluster which results in patients receiving care in a setting that is more expensive and less appropriate.

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The recommendations made by the RSTG that seek to ameliorate some of the current challenges, and improve patient access, experience, quality and value-for-money are included below. Recommendation #1a: Align general musculoskeletal rehabilitation services to patients’ need and within

their local community ensuring equity of access. Recommendation #1b: Rehabilitation services for upper extremity and amputation patients should be

delivered in cluster centres. Recommendation #1c: Develop a plan that will allow post-orthopaedic patients across the LHIN to access

outpatient care as close to home as possible. Recommendation #2: Continue to provide local care, where clinical expertise exists, to trauma and non-

elective patients, including those with manageable cogitative comorbidities. Recommendation #3: Review processes within fracture clinics to identify opportunities for quality

improvements, standardization, and health human resource utilization. Recommendation #4a: Standardize pre-surgical education content for hip and knee replacement and hip

fracture patients based on evidenced best-practice throughout the LHIN. Recommendation #4b: Standardize rehab care for hip and knee replacement and hip fracture patients

based on evidenced best-practice, expert opinion and surgical protocol throughout the LHIN through coordinated care plans.

Recommendation #4c: Review Hand Programs and, based on that review, standardize care for appropriate patient populations.

Recommendation #4d: Standardize rehab care and improve quality for other orthopaedic procedures based on evidenced best-practice, expert opinion and surgical protocol throughout the LHIN through coordinated care plans.

Recommendation #5: Continue to support innovative practices and testing to improve the quality of care.

Recommendation #6: Review information requirements and standardize data collection across sectors to support improvements in access and quality of care.

Recommendation #7: Review services and recommend preventative programming for the Central East LHIN.

The future implementations of the RSTG’s recommendations will be affected by ongoing health system transformation. In particular, implementation of Health System Funding Reform, the Integrated Orthopaedic Capacity Plan, Resource Matching & Referral, and Physiotherapy reform will have a significant impact on implementation planning for musculoskeletal rehab. A number of the recommendations made are quick-wins and it was suggested by the RSTG that these be implemented first to ensure this work has the greatest impact over time. For example, Recommendation #4a, standardization of pre-surgical education, could be easily achieved and it would allow patients to access Hip and Knee schools in any hospital in the LHIN, no matter where they are receiving surgery. Recommendations that are harder to implement will be pursued after quick-wins. For example, Recommendation #6, standardizing data collection across sectors, could be difficult to achieve given varying technology. However, those recommendations are believed to have a high impact. Thus, it is suggested that all twelve recommendations be pursued to enhance, the quality of care, patient experience and access and value-for-money.

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Introduction Work is being done across the province to develop an integrated approach for orthopaedic care. Health System Funding Reform (HSFR) and the adoption of Quality Based Procedures are driving a shift towards funding that follows the patient. There are a variety of planning activities taking place across the province that focus on enhancing capacity to meet the needs of Ontario’s aging population. An expert panel is currently exploring how to best deliver rehabilitation and complex continuing care. Care pathways are being established provincially for hip fractures. In addition, the successful transition of patients from one setting or provider to another has become an important focus. This is being supported, in part, by an expanded role for the CCAC and Resource Matching and Referral (RM&R), an IT solution which will match referred patients to available resources. Planning activities around musculoskeletal rehab services will allow Central East LHIN health service providers to take advantage of health system funding reform and leverage the work that is being done provincially. This work is also an integral component of a successfully designed orthopaedic surgical program as outlined by the Integrated Orthopaedic Capacity Plan (IOCP) that was submitted to the Ministry of Health and Long-term Care on March 30th, 2013. Ensuring rehab services are available to support post-orthopaedic rehab patients in the right place and at the right time is a primary objective of the musculoskeletal rehab services initiative. On the whole, this planning exercise seeks to identify strategic objectives that will result in a regional system of musculoskeletal rehab that will meet the needs Central East LHIN residents while enhancing system capacity and maximizing value for money. This report contains recommendations, developed by representatives from Central East LHIN rehab services providers, that will create such a system.

http://www.centraleastlhin.on.ca/uploadedFiles/Home_Page/Board_of_Directors/Board_Meeting_Submenu/05.4_-_Ortho_Capacity_Plan_-_March_27_2013_Board_Meeting.pdf

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The Planning Process A Rehab Service Task Group (RSTG) was established with a mandate to develop a future state vision for musculoskeletal rehab services in the Central East LHIN. This group met on a bi-weekly basis for five months to share information about the current state of rehab services, identify gaps, and identify activities needed to implement the planned future vision. Specifically the RSTG considered:

• Siting, in principle, for musculoskeletal rehab services; • LHIN wide, cluster and local access; • Current and future (5 year) service capacity (supply) and demand (utilization); • Emerging changes in clinical practice, care pathways, and the use of technology; • Quality and other Performance Standards (e.g., effective, efficient, appropriate, safe, person-centred); • Service program standardization across providers, where appropriate; and • Health human resources

The recommendations for musculoskeletal rehab services were developed in collaboration with the Orthopaedic Surgical Task Group’s (OSTG) IOCP which is discussed in greater detail below. The RSTG has taken into account the need to support regional orthopaedic programming and has further developed some of the recommendations outlined in the IOCP. A number of RSTG members also sit on RM&R which allowed the group to understand how RM&R will change the way patients experience transitions in care. It is intended that RM&R’s activities will complement the future vision articulated in this report.

Membership RSTG membership was made up of representatives from a variety of Central East LHIN health service providers including: each of the LHIN’s eight hospital corporations, community health service providers and the Central East Community Care Access Centre (CECCAC). Central East LHIN support staff also participated in RSTG meetings. Two co-chairs led the work of the RSTG. A list of participants is included in Appendix A.



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Values A set of values were articulated by the RSTG and these values formed the basis of the group’s work. These values were discussed in depth and agreed to early in the planning process. They describe the overall direction that the RSTG believed rehab service provision should evolve towards in the Central East LHIN. Equity of Access All patients will have equitable access to rehabilitation services available within the LHIN – including inpatient, community, home based care, and outpatient services. Services that provide the level of care required, as defined by the literature and clinical expertise, will be made available to patients throughout the LHIN. Care will be based as close to home as possible and will not be dependent on where a patient enters the system. There will be equity of access for urban and rural patients. Services for Priority Populations/ Marginalized Populations Some of the most vulnerable patients in the Central East LHIN require musculoskeletal rehab. This includes patients with comorbidities, such as cognitive impairments, as well as patients whose socio-economic status or living situation means they require specialized care and additional services. Rehab services should be made available to these priority and marginalized populations in a way that meets all patients’ needs. Regional/Cluster/Local Models To ensure that quality care can be provided services will be designed using a model of regional, locals and local programs where there are sufficient volumes of patients to maintain efficiency and competence while respecting patients’ need to be close to home. Standardization for quality outcomes Rehabilitation services will be standardized across the LHIN, including access, care received and discharge, to provide efficient and effective care resulting in quality outcomes. Optimizing patient flow Patient flow will be optimized by providing appropriate levels of care to promote recovery. This will include the use of regional, cluster and local resources as defined in the evidence and ensuring appropriate volumes for quality care. Maximizing Health Human Resources All rehabilitation will be provided by an effectively functioning multidisciplinary team that best meets the needs of the patient while maximizing scope and utilization of health care professionals and support staff. Innovative strategies Innovative strategies will be used to maximize the effectiveness of rehabilitation services in managing patient volume and flow, enhancing sustainability and improving the quality of care. Appropriateness of Rehab Modalities (i.e. home-based, classes, inpatient) Evidence based care will be provided which includes realistic goal setting, home based programs and self-management.

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Preventative Care The rehabilitation care will have a focus on prevention including prevention of complications and future injury prevention. Pre-operative Care Rehabilitation in the Central East LHIN will start pre-operatively by preparing patients for surgery through education and ensuring appropriate levels of physical conditioning to optimize outcomes.

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Current Context

Health System Reform Ontario’s health care system is ever-evolving and changing rapidly. Some changes occurring in coming years will have a great impact on musculoskeletal rehab services. While some details about important initiatives are unknown their anticipated effect was taken into account by the RSTG during this planning exercise.

New Funding models in Ontario Patient-Based Funding (PBF) is being implemented across Ontario over the next few years and will provide the majority of the funding for future health care services. Please see the IOCP for further details. It consists of two key components - Health Based Allocation Model (HBAM) and Quality-Based Procedures (QBPs). Health Based Allocation Model (HBAM) HBAM considers many factors in a complex mathematical formula to decide on funding for services per region. Quality Based Procedures (QBPs) For procedures where it has been identified that there are high volumes and standard practices a new methodology has been developed where each procedure is funded at a predetermined rate. Within Ontario the volumes of hip and knee replacement surgery are controlled by the Ministry of Health and Long Term Care (MOHLTC) and the LHINs which then allocate volumes to the individual hospitals. Funding is provided as a quality based procedure with the following set rates per surgery:

Figure 1: QBP Rates 321: Total Primary Knee Replacement 320: Total Primary Hip Replacement Surgery $6,254 Surgery $7,071 IP Rehab $4,872 IP Rehab $6,073 OP Rehab $554 OP Rehab $628

Physiotherapy On April 18th, 2013 the Minister of Health and Long-term Care announced changes to funding for physiotherapy that would allow 218,000 more patients to benefit from physiotherapy services. Physiotherapy services are to be extended in a variety of settings including: group exercise and falls prevention classes, long-term care homes, patients’ homes, and in the community. LHINs will work with service providers to ensure that the $10 million provided for falls prevention and exercise classes is used to meet local need. Long-term care homes are to receive $68.5 million to directly fund physiotherapy and exercise. Community Care Access Centres are to receive $33 million to reduce wait-lists for physiotherapy. $44.5 million will support services in the community. This announcement is another tool that will allow for the implementation of the recommendations contained in this report.


http://news.ontario.ca/mohltc/en/2013/04/more-physiotherapy-exercise-and-falls-prevention-for-seniors.html

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Integrated Orthopaedic Capacity Plan In anticipation of service modifications required to implement HFSR the MOHLTC requested that the Local Health Integration Networks (LHINs) complete an Integrated Orthopaedic Capacity Plan to provide information on the future vision for hip and knee replacement service delivery in the LHIN, initially considering hip and knee replacement as well as hip fracture. In the Central East LHIN the IOCP provides recommendations on future service delivery models for all orthopaedic populations in the Central East LHIN. This work was undertaken by the Central East LHIN Orthopaedic Surgical Task Group (OSTG). The RSTG sought to align their recommendations with those made by the OSTG. Central recommendations made by the OSTG are outlined below. Key system change #1: Align surgical services using a LHIN-wide/cluster/ local framework which ensures

optimal use of CE LHIN capacity and quality care while keeping the patient as close to home as possible

Key system change #2: Develop a systems approach to trauma access and repatriation Key system change #3: Standardize care for orthopaedics, including hip and knee replacement and hip

fracture, throughout the LHIN through coordinated care plans for inpatient care and rehabilitation.

Key system change #4: Identify a performance measurement system which includes outcomes for orthopaedics

Key system change #5: Complete a review and develop a plan for a coordinated intake system and an interdisciplinary assessment program if it is identified that they will assist in promoting access and standardization in care

Key system change #6: Align rehabilitation services to patients’ need and within their local community Key system change #7: Complete a review and develop a plan for a coordinated staffing model which

supports physician integration including coordinated coverage to maximize efficiencies. This may include LHIN-wide Credentialing, LHIN-wide On-Call; and LHIN-wide Operating Room Efficiency and Scheduling

The table below provides a summary of the recommendations for how future orthopaedic services are to be aligned using a LHIN-wide/cluster/local framework. Patient population Recommendation Non elective and Trauma Local Centres

Cluster or LHIN-wide Centres providing equitable access to specialized surgical services

Hip and Knee Replacement Local Centres Hip and Knee Revision Cluster Centres

LHIN-wide Centre for complex patients including infection Ankle and Foot Cluster Centres Arm, Elbow, Forearm, Hand and Wrist

Local Centres aligned with plastic surgery and hand units

Knee (excluding replacement and revision)

Local Centres

Shoulder Cluster Centres Spine LHIN-wide Centre


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Resource Matching and Referral Resource Matching and Referral (RM&R) is an electronic information and referral system that contributes to the provincial strategies of reducing Emergency Room wait times and Alternative Level of Care days. It is being implemented provincially and all the LHINs have been divided into clusters that are working through a seven-step model developed by the Toronto Central LHIN (see Figure 2 below).

Figure 2

This solution will improve workflow and communication during the referral process, matching patients/clients to earliest available and most appropriate care/support setting. The objective of the current phase (Phase 5) of the project is to standardize and streamline referrals in preparation for the implementation of electronic RM&R solutions. The initial implementation of Provincial RM&R is focused on the following four referral pathways which offer the greatest potential opportunities for improving ALC wait times, with the objective of having one provincial form per care pathway:

• Acute (Medical and Surgical Inpatient) sending referrals to Rehabilitation • Acute (Medical and Surgical Inpatient) sending referrals to Complex Continuing Care (CCC) • Acute (Medical and Surgical Inpatient) sending referrals to Long-Term Care • Acute (Medical and Surgical Inpatient) sending referrals to CCAC In-Home Services

In the absence of clear directions since early 2012, the Central East LHIN had engaged RWS Advisory to develop a streamlined post-acute referral processes for the Acute to Rehabilitation and Acute to CCC referral pathways that can function in both the partial and full implementation states of a LHIN-and ultimately province-wide electronic RM&R solution. The CCC implementation will be rolled out first with implementation occurring separately in each hospital. The lessons learned from the first deployment will be used to guide/refine subsequent implementations.

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Rehabilitative Care Alliance The recently initiated Provincial Rehabilitative Care Alliance is envisioned as:

• A task-oriented group that leverages existing rehabilitative care planning bodies and expertise to optimize rehabilitative care for patients/clients and caregivers (reporting to the LHIN CEO’s through a Lead LHIN model).

• A collaborative with representation from LHINs, Ministry, CCAC and clinical experts from across the province.

• Working closely with various key stakeholders to effect positive changes that support and enhance the adoption and effectiveness of clinical and fiscal priorities within rehabilitative services.

• Complementing the work of groups formed under Ministry direction to define best practices for specific clinical conditions that will be funded as Quality Based Procedures (QBPs) under the multi-year Health System Funding Reform (HSFR) initiative.

• Being inclusive of rehabilitative services in all clinical settings, including a focus on Assess and Restore services, and ensuring that implementation can occur throughout the province.

A key first step of the work involves consultation and engagement with provincial partners regarding top priorities that the Alliance should be working on. These priorities will form the work plan for the Alliance for the next two years. Given the formative nature of these activities, the mandate of The Rehabilitative Care Alliance will continue to evolve over the coming months.

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Demographics and Demand for Musculoskeletal Rehab The Central East LHIN has the second largest population in Ontario. It is home to 1,572,500 people or 11.8 percent of Ontario’s population. The Central East LHIN also has the fourth highest projected growth rate. It is expected that by 2021 the population will have increased by 17.0 percent, compared to a projected increase of 13 percent for Ontario overall (IHSP Environmental Scan). Figure 3 below shows the population distribution by age for each of the three Central East clusters as well as Ontario. The largest population age group is 40-59 for all clusters and Central East has a higher percent of residents than Ontario at large in every age group 50+. A growing and aging population will result in increased demand for orthopaedic surgery and musculoskeletal rehab, putting pressure on the system. It is important to note that annual growth rates and population distribution varies by geographic area. The 45-74 year age cohort will increase 5.5 percent in the North East, 11.8 percent in Scarborough and 15.0 percent in Durham by 2020, resulting in an overall population increase of 68,777 in that age cohort. The majority of patients that require orthopaedic services are between 50 and 70 years of age. Demand for musculoskeletal rehab is expected to increase overall, in all three clusters, as a result. Projections for Orthopaedic procedures contained in the IOCP indicate that demand for Hip and Knee Replacements, and the rehab associated with those procedures, will increase the most in the Durham cluster.

Source: IHSP Environmental Scan, 2011 Census

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

0-9 10-19 20-29 30-39 40-49 50-59 60-64 65-74 75+

Perc

ent o

f Tot

al P

opul

atio

n

Age Group

Figure 3: Population Distribution by Age Group

North East Cluster

Durham Cluster

Scarborough Cluster

Central East LHIN

Ontario

http://www.centraleastlhin.on.ca/uploadedFiles/Home_Page/Integrated_Health_Service_Plan/Provincial_LHINs_Environmental_Scan_-_Technical_Document_September_2012.pdf


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The report Building a Model of Sustainable Access to Community Health Care Services noted that the “CE LHIN’s acute programs that require the greatest increase in shares over time are associated with circulatory, musculoskeletal and connective, and cancer care”. This is driven by older patients that require a high-level of health care services. One percent (15,300) of the CE LHIN’s population uses 53 percent of total services. Service use among the CE LHIN’s population aged 65 and older is less concentrated: 1 percent of this population (2,100) uses 32 percent of all acute services received by the LHIN’s 65 and over population. These patients are typically seniors that have multiple co-morbidities and challenging socio-economic conditions that require intensive use of health and social services. These patients often have CHF, COPD and/or dementia. Socio-economic pressures also play a role in patients’ utilization of the health care system. For example, a high number of elderly patients live alone in the Central East LHIN (see Figure 4 below). These patients tend to have fewer supports, and are at greater risk for falls. As the population ages in the Central East LHIN there will be a larger number of patients that require relatively intensive health and social services.

Figure 4: Seniors Living Alone

Percent of population 65 to 74 living alone 15.9%

Percent of population 75 to 84 living alone 28.6%

Percent of population 85+ living alone 40.9%

Percent of population 65+ living alone 22.6% Source: Sub-LHIN Planning Area Profile of Seniors, Census 2006

The Central East LHIN spends more for seniors than high-performing LHINs. CE LHIN’s spending per senior in 2009/10 was $5,579, similar to the provincial average but 12 percent more than spending by the high performing LHIN. From 2006/07 to 2009/10, CE LHIN’s Acute and Home Care expenses increased by approximately 20 percent. Over the same period, mental health, CCC, and inpatient rehabilitation expenses increased by 8 percent, similar to the growth in age-weighted population. Inpatient rehab and CCC can often best support the needs of the frail seniors with complex needs. These beds are also less expensive than acute care beds; however investment in the Central East LHIN has been directed to acute care beds. It is essential that the capacity in inpatient rehab be appropriate for the Central East’s aging population and that rehab capacity is sustainable. Increasingly, inpatient rehab focuses on the most complex patients. Due to technological advances patients with less complex needs can be rehabilitated in an ambulatory environment. Continuing to move those lower-intensity patients into ambulatory and community settings would allow inpatient settings to focus on seniors with complex needs. Thus retooling bed capacity could improve outcomes for those high-users and enhance capacity within the system by reducing ALC rates. Although all recommendations contained within this report are made to support increases in system capacity, Recommendation #1 specifically addresses this issue by identifying the need for increases in outpatient rehab services.

http://www.centraleastlhin.on.ca/uploadedFiles/Home_Page/Board_of_Directors/Board_Meeting_Submenu/SA_Report_-_FINAL_June_2.pdf

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Current State of Rehab Services in the Central East LHIN Rehabilitation services are provided across the continuum of care. Patients may receive rehab within the hospital sector either in an inpatient Rehab Bed, a CCC bed or an Acute Care bed. Hospitals also offer rehab services on an outpatient basis. Currently, other patients receive publicly funded care on an outpatient basis through OHIP funded physiotherapy clinics. Rehab is also provided by the CCACs in patients’ homes for those who cannot access outpatient clinics. Rehab professionals also work within Long-term Care Homes and these services may be funded by OHIP. Those that can afford it may also obtain rehab privately. In the Central East LHIN rehab services are currently provided in each of these settings depending on patients’ clinical needs, their personal circumstances and where they live. This report focuses on the care provided to musculoskeletal patients that received orthopaedic surgery. Other musculoskeletal patients were considered where appropriate including non-surgical patients and those that received plastic surgery.

Acute Orthopaedic Care The appropriate level of musculoskeletal rehab services must be available to support Orthopaedic Surgical care, thus an understanding of the surgical services provided in the Central East LHIN was required. Within the Central East LHIN there are 5 hospitals that provide orthopaedic services with a total of 8 primary sites. These are:

• Lakeridge Health Corporation – Oshawa and Bowmanville • The Scarborough Hospital – both the Birchmount and General sites • Peterborough Regional Health Centre • Rouge Valley Health System –Centenary and Ajax sites • Ross Memorial Hospital, Lindsay

There are an additional 3 hospitals: Campbellford Memorial Hospital (Campbellford), Haliburton Highlands Health Services Corporation (Haliburton) and Northumberland Hills Hospital (Cobourg) where trauma patients may enter the health care system. Please see the IOCP for information regarding orthopaedic surgical volumes and performance. That data was utilized by the RSTG in planning. Interestingly, a disproportionately low number of elective orthopaedic procedures are done in the Central East LHIN given the population (see Figure 5 below). With the exception of Primary Unilateral Knee Replacement, only orthopaedic procedures that are associate with a trauma or non-elective patients have volumes that appear to be in-line with the Central East LHIN’s population, 11.8 percent of Ontario’s population. This conforms to the premise that many Central East LHIN residents seek surgery in other LHINs, such as the Toronto Central LHIN. Based on population characteristics it is expected that Central East LHIN residents require orthopaedic care in similar, or higher, numbers as other LHINs. For example, as mentioned in the IOCP the Central East LHIN has a larger proportion of residents over the age of 50. Also, the Central East LHIN has roughly 11.7 percent of Ontario’s population in this age group (IHSP Environmental Scan). Figure 6, below, demonstrates that a fairly high number of Central East LHIN residents seek care in other LHINs. Since 2009 between 3,730 and 4,137 patients have gone outside of the Central Eat LHIN to obtain orthopaedic care each year. This compares with between 1,578 and 1,638 patients that have travelled from elsewhere each year to obtain orthopaedic care within the Central East LHIN since 2009.



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The outflow of patients to other LHINs has important consequences for rehab services in the Central East LHIN. Many patients who receive surgery in other LHINs will likely seek rehab closer to home; and the RSTG agreed that, in principle, rehab should be available as close to home as possible. Patient flow from surgery to rehab across LHINs is not tracked. The exact volumes of patients that receive surgery in other LHINs and then return home for rehab is unknown. However, given that fewer surgeries are performed in the Central East LHIN than its population warrants it is plausible that a push towards more community-based rehab will result in demand for rehab services that will be larger than current surgical volumes and projections suggest.

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Figure 5: Proportion of Ontario’s Orthopaedic Procedures Performed in the Central East LHIN

Location

Acute Volume of procedures performed annually by Orthopaedic QBP*

Primary Unilateral

Hip Replacem

ent

Primary Unilateral

Knee Replacem

ent

Revised Hip

Replacement

without Infection

Revised Knee

Replacement

without Infection

Hip Replacement with

Trauma/Complicati

on of Treatmen

t

Fixation/Repair

Hip/Femur

Replacement/Fixation/Repair

of Tibia/F ibula/ Knee

Fracture of Femur

Major Foot

Intervention except

Soft Tissue

without Infection

Shoulder/Rotator

Cuff Interventi

on

Reduction/Fixation/

Repair Upper

Body/Limb except

Fixation/Repair of

Shoulder

Reduction/Fixation/Repair of

Ankle/Foot

Other Fracture/Dislocatio

n of Arm/Shou

lder

Fracture/Dislocation/Rupture

of Pelvis/Sacrum/Cocc

yx

Central East LHIN Total 857 2,150

61

95 485 846

271 208 87 94 305 326 75 234

Ontario Total 11,430 21,367 1,215 1,062 4,055 7,319 3,016 1,767 1,162 1,166 4,020 3,415 1,026 2,210 Central East percent of Total Procedures

7% 10% 5% 9% 12% 12% 9% 12% 7% 8% 8% 10% 7% 11%

Source: HAB

Figure 6: Orthopaedic* Care Inflow and Outflow Year CE Residents receiving care in the

CE LHIN CE Residents receiving care

outside the CE LHIN Non-CE Residents receiving care inside

the CE LHIN

2009 7,129 3,730 1,638 2010 6,998 3,775 1,627 2011 6,986 4,137 1,578

Source: intelliHEALTH *a list of CMGs that are included is contained in Appendix B

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With the implementation of QBPs targets have been set for discharge disposition of 90 percent home and for length of stay of 4.4 days for patients discharged home. Currently, all hospitals in the Central East LHIN have exceeded these targets (see Figure 7 below). This is due, in part, to some of the innovations and best practices discussed below.

Figure 7: Orthopaedic Quality Score Care Hip and Knee Replacement Q4 2012/13

Quality Dimension Efficiency

Hospital Name Total Volume

Length of Stay - All Patients (Average

Days)

Patients Discharged Home

Average Length of

Stay in days

(Target 4.4 days)

Median Length of

Stay (Days)

90th Percentile Length of

Stay in days (Target 7

days)

Percent completed within 4.4

days

Percent completed

within 7 days

Proportion of Patients

Discharged Home

(Target 90percent

±9%)

Central East 220 3.8 3.6 4 5 87.4 99.5 90.0

ROSS MEMORIAL HOSPITAL 22 2.8 2.8 2 4 90.5 100.0 95.5 PETERBOROUGH REGIONAL HEALTH CENTRE 52 4.2 4.1 4 5 80.9 100.0 90.4 LAKERIDGE HEALTH CORPORATION 43 3.5 3.5 3 5 85.4 100.0 95.3 ROUGE VALLEY HEALTH SYSTEM 59 3.5 3.3 3 4 92.3 100.0 88.1 SCARBOROUGH HOSPITAL (THE) 44 4.5 4.0 4 5 89.2 97.3 84.1

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Inpatient Rehab Inpatient care is provided in a hospital bed and often includes assessment and treatment (including Physiotherapy and Occupational Therapy), discharge planning, exercise prescription and referral to other services as required. Musculoskeletal inpatient rehab is offered by five hospital corporations in the Central East LHIN:

• Rouge Valley Health System (Centenary and Ajax/ Pickering Sites) • Lakeridge Health (Whitby and Oshawa Sites) • Peterborough Regional Health Centre • Ross Memorial Hospital • Northumberland Hills Hospital

These five hospitals all have dedicated rehab units, although care is often provided in other beds as well. The type of patient that is typically treated in various units is presented below in Figure 8. Campbellford Memorial Hospital does not have defined rehab services but does provide inpatient physiotherapy in their Acute Care beds. The Scarborough Hospital does not offer inpatient rehab for orthopaedic patients - patients who require inpatient rehab are referred to Providence, Bridgepoint, Baycrest, or St. Johns prior to surgery. The Scarborough Hospital does have a large inpatient amputee program. Patients are seen by PT, OT and Rehab Assistants daily and are instructed in stump care, wrapping, transfers, equipment, and ADL’s. At Lakeridge Health and Peterborough Regional Health Centre amputee patients return to inpatient rehab for prosthetic training following surgery. Occupational Therapy, Physiotherapy, Prosthetist, Nursing, Physiatry, Rehabilitation Assistant focus on returning the patient to normal movement and mobility. Once the patient is safe to mobilize independently, the patient is discharged home. Outpatient services are offered at Lakeridge Health for continued gait training.

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Figure 8: Conceptual Framework: Functional Groups

Group No.

Functional Group Description

Potential for

Functional Recovery

Medical Complexity

Psychosocial Complexity

Lakeridge Health Ross Memorial Hospital

Peterborough Regional Health

Centre

Rouge Valley Health Centre

Northumberland Hills Hospital

1

Slow progress/low capacity for functional improvement

Low High High

• Geriatric Assessment

and

Rehabilitation Unit

• Complex

Continuing Care

– complex medical

• Complex Continuing Care,

functional

Enhancement Unit (Medicine)

• Restorative care beds

2

Slow to moderate progress/low to moderate capacity for functional improvement

High High Low

• Geriatric Assessment

and

Rehabilitation Unit

• Complex Continuing Care

– Functional

Enhancement/ Assess and

Restore

• Complex

Continuing Care

• GATU

• FE

• Restorative care beds

3

Moderate to rapid progress/moderate to high capacity for functional improvement

High High High

• Integrated Stroke Unit

• Restorative Care Unit

• Inpatient Rehabilitation

• Rehabilitation Beds

• TRCP • Rehabilitation beds

4

Rapid progress/high capacity for functional improvement

High Low Low

• Integrated Stroke Unit

• Inpatient

Rehabilitation Unit

• Inpatient

Rehabilitation or community

based

rehabilitation

• Rehabilitation Beds

• STR • Rehabilitation beds

5

Lifelong condition/periodic need for rehabilitative interventions

Low* High* High*


(Whitby,

Bowmanville

and Oshawa sites)


– Functional

Enhancement/

Assess and Restore

• Complex

Continuing Care

• Transitional –ALC ( RVC

and RVAP)

* inferred from framework description in “rehabilitation & CCC Expert Panel Update” Presentation, February 2012

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Due to the variety of patients that receive rehab and the various settings in which care is provided it is not possible to obtain a complete picture of the volume of inpatient services provided in the Central East LHIN. For example, the volume of patients receiving rehab in acute care beds is not collected. The data on patient volumes that is available is presented in Figure 9 below. This data was collated to support the development of the IOCP. Due to the complexity of collecting this data, 2012/13 data was not provided. Volumes for hip and knee replacements, in particular, will have changed since the 2011/12 fiscal year due to the discharge home targets mentioned above. Hip and Knee replacement patients receive a large share of rehab services, thus increasing the number of these patients that are discharged home will make beds available for higher intensity patients. Guidelines for hip fracture patients are currently being developed by the Ministry of Health and Long-term Care in preparation for the implementation of that QBP. This is also a fairly high volume patient group in rehab, thus inpatient volumes by QBP will likely continue to change.


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Figure 9: Volume of inpatient rehabilitation services provided by QBP and other orthopaedic procedures

Orthopedic QBPs

Acute Inpatient Rehab QBP Funded Not QBP Funded in 2012/13 Sum of inpatient

rehab, CCC, and patient receiving

rehab in acute volumes per QBP

Percent of Surgical Volume

receiving inpatient

rehab

Volume of procedures performed

annually

Volume of Rehab Patients Admitted to a

designated rehab bed per

QBP

Volume of CCC Patients

Admitted per QBP

Volume of patients

receiving rehab in an acute care

bed per QBP

(a) (b) (c) (d) (e) = (b+c) (f) = (e/a) Orthopedic QBPs e = (b+c) f = (e/a) (317) REVISED HIP REPLACEMENT WITHOUT INFECTION 61 28 5 NA 33 54.1% (319) REVISED KNEE REPLACEMENT WITHOUT INFECTION 95 26 3 NA 29 30.5% (320) UNILATERAL HIP REPLACEMENT 877 223 8 NA 231 26.3% (321) UNILATERAL KNEE REPLACEMENT 2157 405 25 NA 430 19.9% (334) MAJOR FOOT INTERVENTION EXCEPT SOFT TISSUE WITHOUT INFECTION 87 6 0

NA 6 6.9%

(341) SHOULDER/ROTATOR CUFF INTERVENTION 94 0 0 NA 0 0.0% (726) HIP REPLACEMENT WITH TRAUMA/COMPLICATION OF TREATMENT 485 227 41

NA 268 34.1%

(727) FIXATION/REPAIR HIP/FEMUR 846 355 67 NA 422 49.9% (729) REPLACEMENT/FIXATION/REPAIR OF TIBIA/FIBULA/KNEE

271 25 6 NA 31 11.4%

(739) REDUCTION/FIXATION/REPAIR UPPER BODY/LIMB EXCEPT FIXATION/REPAIR OF SHOULDER

305 7 4 NA 11 3.6%

(747) REDUCTION/FIXATION/REPAIR OF ANKLE/FOOT 326 16 6 NA 22 6.7% (761) FRACTURE/DISLOCATION/RUPTURE OF PELVIS/SACRUM/COCCYX

234 91 33 NA 124 53.0%

(766) FRACTURE OF FEMUR 208 11 6 NA 17 8.2% (770) OTHER FRACTURE/DISLOCATION OF ARM/SHOULDER 75 8 4

NA 12 16.0%

Total Select Orthopaedic CMGs 6121 1428 208 1636 Source: Ministry of Hea lth and Long-Term Ca re, Health Analytics Branch

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Outpatient Rehab A wide range of outpatient rehab services are offered by hospitals in the Central East LHIN. Services include assessment, exercise classes, Hip and Knee classes, OT, PT, sensory testing, splinting, scar management, preventative care etc. The Scarborough Hospital (General Campus), Rouge Valley Health System (Centenary and Ajax/ Pickering Sites), Lakeridge Health (Whitby, Oshawa, Bowmanville and Port Perry Sites), Peterborough Regional Health Centre and Haliburton Highlands all have outpatient clinics that offer musculoskeletal rehab, including fracture clinics. There are hand programs at The Scarborough Hospital, Rouge Valley Health System, Lakeridge Health (Oshawa and Fracture Clinic Sites) and Peterborough Regional Health Centre. Haliburton Highlands Health Services offers only physiotherapy. As mentioned above Lakeridge Health also serves amputation patients on an outpatient basis.

Data collection for outpatient volumes is inconsistent (see Appendix C for a variety of outpatient rehab volume indicators) and it is not possible to obtain a clear picture of outpatient musculoskeletal rehabilitation. In 2012/13 The Scarborough Hospital had roughly 15,000 musculoskeletal outpatient visits and the Rouge Valley Centenary site in the Scarborough cluster had roughly 5000 musculoskeletal outpatient visits. All types of rehab patients visited either the Centenary or Ajax site of Rouge Valley Health System 51,898 times in 2012/13. 57,020 inpatient and outpatient attendances occurred in 2012/13 at Lakeridge Health’s Advanced Rehabilitative Care sites. Significantly less outpatient care is provided in the North East cluster. There were 16,218 clinical in-house attendance days in 2012/13 at Peterborough Regional Health Centre, and Haliburton Highlands Health Services had roughly 2,100 outpatient visits for all diagnoses.

Community Musculoskeletal rehab is also offered in the community by both the Central East Community Care Access Centre (CECCAC) and other community health service providers. The CECCAC offers in-home physiotherapy and occupational therapy for post-surgical orthopaedic patients. A CECCAC Care Coordinator assesses patients utilizing standard tools which include the RAI-CA or RAI-HC. This assessment information contributes to the determination of eligibility for CCAC services. A patient is eligible for CCAC in-home therapy services if they are unable to access services on an outpatient basis. Therapy services provided by the CECCAC may include; post-operative orthopaedics surgery care, therapeutic exercise and strengthening, assessment for mobility and transfer aids, ADP funding for equipment, safety assessments for in the home and for accessing the community, gait training, balance, coordination and falls prevention, prescription and training for lower extremity bracing or orthotic devices, and pain management. Currently the CECCAC follows the Total Joint Network guidelines for total knee replacement and total hip replacement in all geographical areas except those patients that have had surgery at the Ross Memorial Hospital and Peterborough Regional Health Centre. Patients having hip or knee replacement surgery at Ross Memorial Hospital or Peterborough Regional Health Centre are brought on for service regardless of their ability to access outpatient physiotherapy due to the lack of outpatient clinics (see Current Challenges below). Homemaking, Lab and Social Work are also provided by the CECCAC as per their Service Planning Guidelines. These guidelines have been developed for all services offered by the CECCAC and are based on evidenced best practice. Consistent planning has resulted in a decrease in overall utilization; and, utilization rates compare well provincially with other CCACs. The volumes of post-orthopaedic patients that receive CECCAC care is presented in Figure 10 below. Data for patients who receive out-patient and community care in other settings is not available.

Other services are offered by community health service providers. For example, educational and preventative programming is offered by Community Health Centres. The Port Hope Community Health Centre offers falls prevention, exercise, arthritis and osteoporosis classes. Many of preventative services are provided by hospitals

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as well through programs such as the GAIN strategy. Community Care City of Kawartha Lakes also offers falls prevention classes; and, some physiotherapy and occupational therapy is offered to clients free of charge.

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Figure 10: Volume of Ambulatory Care and Community rehab provided by QBP and other orthopaedic procedures

Orthopedic QBPs

Ambulatory and Community Rehab QBP Funded QBP Funded Not QBP Funded in 2012/13 Volume of CCAC cases

Volume of Hospital

Outpatient cases

Volume of cases performed at Other Publicly

Funded Providers (e.g. CHC)

Unique Cases in

Short Stay Community

Beds

Unique cases in

community clinics (e.g.

DPC)

Total unique cases in

Ambulatory and Community

Rehab

(g) (h) (i) (j) (k) (l) (317) REVISED HIP REPLACEMENT WITHOUT INFECTION

13 NA NA NA NA NA

(319) REVISED KNEE REPLACEMENT WITHOUT INFECTION

27 NA NA NA NA NA

(320) UNILATERAL HIP REPLACEMENT 330 NA NA NA NA NA

(321) UNILATERAL KNEE REPLACEMENT 618 NA NA NA NA NA (334) MAJOR FOOT INTERVENTION EXCEPT SOFT TISSUE WITHOUT INFECTION

11 NA NA NA NA NA

(341) SHOULDER/ROTATOR CUFF INTERVENTION 4 NA NA NA NA NA (726) HIP REPLACEMENT WITH TRAUMA/COMPLICATION OF TREATMENT

38 NA NA NA NA NA

(727) FIXATION/REPAIR HIP/FEMUR 54 NA NA NA NA NA (729) REPLACEMENT/FIXATION/REPAIR OF TIBIA/FIBULA/KNEE

12 NA NA NA NA NA

(739) REDUCTION/FIXATION/REPAIR UPPER BODY/LIMB EXCEPT FIXATION/REPAIR OF SHOULDER

16 NA NA NA NA NA

(747) REDUCTION/FIXATION/REPAIR OF ANKLE/FOOT

19 NA NA NA NA NA

(761) FRACTURE/DISLOCATION/RUPTURE OF PELVIS/SACRUM/COCCYX

28 NA NA NA NA NA

(766) FRACTURE OF FEMUR 8 NA NA NA NA NA (770) OTHER FRACTURE/DISLOCATION OF ARM/SHOULDER

6 NA NA NA NA NA

Total Select Orthopaedic CMGs 1184

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1. Methodology developed in collaboration with the Central East LHIN Hospitals: Source: DAD, Intellihealth, FY 2011-12 b= cases with institution to type of Rehab (general or special) c = cases with institution to type of CCC g= cases with institution to type of HOME with without supports h to l = cases with discharge dispositions of: i . Discharged home ii . Discharged to home or home setting with support (excluding Home Care institution to type) iii . Transferred to CONTINUING care (excluding General Rehab, Chronic, Extended, Nursing Home and LTC institution to types)

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Best Practices and Innovations

A culture of continuous improvement exists within the Central East LHIN. A number of innovations have been successfully implemented that have resulted in improved quality of care, efficiency, and patient satisfaction. For example, Rouge Valley Health System, Lakeridge Health, Peterborough Regional Health Centre and Northumberland Hills Hospital have implemented, or are in the process of implementing, a co-managed medical model that utilizes Nurse Practitioners to improve patient, family and nursing satisfaction. A newly emerging innovation at Northumberland Hills Hospital and Ross Memorial Hospital is the creation of a Rehab Patient Navigator role. Interdisciplinary care team members provide a single point of contact for patients and families to facilitate weekly goal setting and smooth discharge transition. Many innovations that have been implemented over the years have become best-practice across the LHIN. All hospitals utilize Rehab Assistants, Physiotherapy Assistants and Occupational Therapy Assistants to improve value-for-money and maintain patient outcomes. The implementation of Group Classes for Total Knee Replacement patients has also become a best practice across the LHIN. These classes ensure excellent patient outcomes and provide better value-for-money than one-on-one therapy. Quality Improvement initiatives, such as those based on LEAN or Kaizen methodologies, have greatly improved performance across the Central East LHIN. For example, Lakeridge Health increased capacity in its outpatient clinic by standardizing practices in scheduling, appointment times, wait list management and care maps across all outpatient sites. At Ross Memorial Hospital, Quality Improvement initiatives resulted in several changes such as eliminating the use of urinary catheters post-operatively, getting patients up the day of surgery, improved pain management, and scheduling an earlier follow-up visit in the fracture clinic. Ross Memorial Hospital achieved a reduction in the post-operative length of stay for joint replacements from 6.1 to 2.7 days. Seniors’ friendly programming is increasingly becoming a best practice in rehab in the CE LHIN. These programs aim to coordinate care across settings and prevent functional decline so that seniors’ can return to their own homes and communities sooner and healthier. The Scarborough Hospital has implemented seniors’ friendly programs throughout the organization. Northumberland Hills Hospital and Ross Memorial Hospital have established roles to coordinate seniors’ programming and care and lead the Seniors Steering Committee. Rouge Valley Health System and Ross Memorial Hospital have implemented a program called HELP that utilizes volunteers to reduce hospital-induced deterioration. Lakeridge Health has an Elder Care Steering Committee which advises the Senior Management Team, ensuring all new initiatives are meeting best practices for seniors. At Peterborough Regional Health Centre a cross-corporate Seniors Friendly Steering Committee and a framework have been established to develop seniors’ friendly initiatives across clinical programs. Peterborough Regional Health Centre is currently a pilot site for evaluating seniors’ friendly indicators of functional decline. In the near future Peterborough Regional Health Centre is planning to implement the MOVE ON program which is an inter-professional approach that focuses on early and consistent mobilization of older patients through their hospital stay. One very positive improvement that has been implemented across the LHIN is that patients generally receive inpatient rehabilitative care as needed, regardless of cognitive comorbidities, preventing functional decline. Practices have been put in place to ensure patient safety and increased involvement of family, allowing more patients with cognitive comorbidities to return home quickly.

http://www.caho-hospitals.com/what-we-do/artic/move-on/

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Access to real-time information has always been a challenge with the unreliability of NRS reporting system to track functional improvement. At Peterborough Regional Health Center, the hospital has invested in a real-time web based software to look at functional change using FIM on a real time basis. Further real time functional outcomes and changes in patients inform multi-disciplinary teams of targets with respect to expected length of stay and utilization management. Lakeridge Health has a web-based waitlist management system that allows both sender and receiver to view patient information and provides a transparent list of patients that have been approved. NHH also has an electronic wait-list that supports musculoskeletal patients by compiling onsite and offsite referrals to their post-acute care specialty services. One very important innovation is the LHIN-wide implementation of pre-surgical education programs for total joint replacement patients. These programs may be run either by rehab or surgical departments. Pre-operative education helps patients prepare for their surgery and recovery. The management of patient expectations is an important element of this education. Education is offered through pamphlets, detailed booklets, group classes as well as one-on-one appointments with Occupational Therapists and Physiotherapists. The home environment is assessed and patients are educated on the use of assistive devices, transfers, weight bearing, exercises, ALDs, IADLs, and the management of their condition at home. At many organizations pre-operative education is credited with reducing LOS to below the targeted 4.4 days and increasing the number of patients discharged home to between 80 percent and 90 percent. Rouge Valley Health System has enhanced their pre-operative programs by implementing “prehab”, an exercise program. This is discussed in more detail in Recommendation #5. Past successes from innovative practices suggest that continued support for innovation will be beneficial.

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Current Challenges Although high-quality rehab is offered in the Central East LHIN, service providers face a number of challenges. As mentioned throughout this section, data collection is limited. This poses challenges not only for LHIN-wide planning, but also for planning individual patient’s care. Some referrals are still paper-based and patient care is not tracked across organizations. As a result, it is difficult for providers to understand the care that their patients are getting and they cannot ensure that all are receiving the most appropriate care. There is no way to determine discrete visits of individuals across organizations. This poses obvious challenges for fee-for-service funding models, and it makes planning for QBPs difficult as current demand is not well understood. Also, separating orthopaedic patient volumes from musculoskeletal rehab patient volumes is typically not possible with the data provided. In fact, the distinction is arbitrary and this posed challenges for this planning initiative. All hospitals are challenged by bed pressures. Patients from units with the highest need are prioritized and this means that patients do not always receive the most appropriate care. Generally, the system is coping and patients are receiving the care they require. However, best practices are not always met and any increases in patient volumes would be extremely challenging given current financial realities. It is established best practice to provide 7-day a week therapy and this is known to improve patient outcome. However, this is not currently provided by any hospital within the Central East LHIN. Staffing models, scheduling practices, funding pressures and professional culture prohibit hospitals from providing care over the weekends. Importantly, current collective agreements may require additional compensation for physiotherapists that work over the weekends creating additional fiscal pressures. Also, there is an expectation among physiotherapists that they will work during business hours. Unless all hospitals in an area require their physiotherapists to work some weekends those that do provide 7-day a week therapy will not be competitive employers. A shift in professional culture toward patient-centric care is required. A number of alternatives to 7-day a week therapy have been implemented that improve the quality of care and patient outcomes. At Northumberland Hills Hospital and Ross Memorial Hospital a Physiotherapy Assistant, Occupational Therapy Assistant, Rehab Assistant, or Orderly completes delegated activities with Rehabilitative and Restorative Care patients over the weekend, including a “Weekend Walking Program”. Peterborough Regional Health Centre recently conducted an external review of its allied therapies through GE Health care with a focus on rehab optimization and revenue generation and is currently reviewing / implementing recommendations. At Lakeridge Health, Rouge Valley Health System and Ross Memorial Hospital 7-day a week therapy is provided for targeted populations, including post-operative total joint and hip fracture patients. The Scarborough Hospital makes Physiotherapists and Physiotherapy Assistants available on Saturdays at the Birchmont campus and over the whole weekend at the General campus. Due to staffing models, there is no vacation coverage for physiotherapists. As a result, patient to therapist ratios are sometimes lower than is considered best practice. The frequency and intensity of rehab is reduced and this has a negative impact on LOS and conservable days. Service providers in the North East Cluster face additional challenges. The smaller hospitals are unable to offer comprehensive rehab services due to funding and recruitment challenges. Patients may still be transferred to these hospitals following surgery only to be transferred again when a rehab bed becomes available elsewhere. In addition, there is only one OHIP funded physiotherapy clinic in the North East Cluster (see Figure 11 below). This means that patients must seek private care, or obtain it from other public health service providers. As a result, the modality of care provided is often not the most efficient or appropriate care. Patients are often

30

served in their own homes by the CCAC when outpatient therapy would be most appropriate from a clinical perspective.

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Figure 11: OHIP Funded Physiotherapy Clinics in the Central East LHIN

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Rehab Services Recommendations

Aligning Care to Patient Need

Recommendation #1a: Align general musculoskeletal rehabilitation services to patients’ need and within their local community ensuring equity of access. Recommendation #1b: Rehabilitation services for upper extremity and amputation patients should be delivered in cluster centres. Recommendation #1c: Develop a plan that will allow post-orthopaedic patients across the LHIN to access outpatient care as close to home as possible.

Rationale As mentioned above, patients that access rehabilitation often have highly complex needs due to comorbidities or socio-economic factors. A rehabilitation plan must account for situations such as: the senior patient who is the caregiver for a spouse at home; a less than ideal home environment; or the fact that a senior may be living alone. Providing access to rehabilitation services closer to home, and where possible in that patient’s local community, is a key value of service planning in the CE LHIN as access to care close to home positively impacts complex patients’ outcomes. Currently, access to the modality of care received is influenced by where a patient lives. For the most part, patients’ needs are being met, however the most appropriate care is not necessarily provided. In particular, patients in the North East cluster have limited access to outpatient services due to travel requirements and the lack of OHIP funded physiotherapy as mentioned above. Unlike surgical services, it is not realistic for patients to travel long-distances to obtain outpatient rehab. Many are able to drive only within their local community or they must rely upon community transportation to access services. Patients are therefore served by less cost-effective in-home services, despite a clinical ability to tolerate out-patient rehab. Given the financial imperatives of the day, it is important that high-quality, efficient rehabilitation services are offered. The outpatient rehabilitation setting can provide cost-effective options such as group therapy for post-operative patients who have had total joint replacements. By improving access to these services, a more efficient utilization of regional resources may be realized as compared to individual in-home therapy. Retooling bed capacity could improve outcomes for high-users and enhance capacity within the system by reducing ALC rates. Community-based rehabilitation services can also facilitate increased capacity and better utilization of inpatient resources. The creation of regionally coordinated patient flow maps, contained within Recommendation #4, will facilitate services planning by identifying the most appropriate modality of care. To ensure smooth discharge transitions from inpatient rehabilitation to the community, the Community Care Access Centre can more effectively facilitate discharge planning from hospital into the local community, thereby optimizing patient flow and ensuring that the appropriate rehab modalities are utilized to promote recovery. Each local community also has programs and services which can be optimized to further facilitate successful recovery at home. Therefore, service planning will be completed to ensure that all clients are able to access high-quality inpatient and outpatient rehabilitation as close to home as possible.

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Improving efficiency and ensuring that resources are available to meet all patients’ needs is only one of the goals of service planning. To preserve quality volumes must be sufficient to maintain the necessary infrastructure and clinical competencies. Thus the quality of care provided and efficiency go hand-in-hand. Due to the clinical complexity of care provided to upper extremity and amputation patients, service provision at a cluster level is recommend. Volumes in the Central East LHIN will not allow providers at local centres to maintain clinical competency, nor will service provision be efficient.

Planning to offer care that has been coordinated across the LHIN will help to maintain quality, improve efficiency and allow patients to access appropriate care as close to home as possible.

Key Objectives Improve access Improve patient experience Better value-for-money and service sustainability Promote efficiency and competence Optimize patient flow and rehab modalities to promote recovery

Implementation Planning for siting and sizing could be done by cluster level to ensure that the care provided suits local needs. Activity Responsible Estimated Time

Develop working group RSTG Short-term Inform allocation for of physiotherapy resources Working Group/ LHIN Short-term Complete siting and sizing for inpatient, outpatient, community based and in-home rehab

Working Group/ LHIN Short-term

Inform allocation methodology for Rehab QBPs Working Group/ LHIN Short-term Implement changes Working Group/ LHIN Short-term

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Trauma and Non-Elective Patients

Trauma and non-elective patient groups are considered separately from those who receive orthopaedic surgery on an elective basis. For trauma and non-elective patients the surgical event is generally sudden, unexpected, and unplanned. It is equally important, however, that patients receiving this type of orthopedic surgery also receive timely rehabilitation following their surgery. Recommendation #2: Formalize relationships between Central East LHIN institutions to continue to provide local care, where clinical expertise exists, to trauma and non-elective patients, including those with manageable cogitative comorbidities.

Rationale A key recommendation from the IOCP is that trauma and non-elective orthopedic services should be delivered at a local level with the exception of specialized care that may be more appropriate at the cluster, or LHIN-wide level. In an effort to increase value to the patient and the system a corresponding local plan for rehab is required. Care will be based as close to home as possible and access should be equitable for both urban and rural patients. Continuing rehab care locally, or in the same organization reduces the amount of planning and coordination that would be required if there were multiple locations and partners providing care. At present trauma and non-elective patients in the Central East LHIN receive high-quality rehab care locally. Although data is limited it was generally felt that these rehab patients are able to access care in a timely manner and that the system is functioning effectively in most cases. However, sometimes patients are transferred to smaller rural hospitals without rehab beds to wait for a rehab bed in the same hospital in which they received their surgery. Coordination is challenging due to differing IT systems and assessment tools. Access to transportation services and the impact of transportation processes and cost has been identified as an obstacle for patients receiving regional rehabilitation care, particularly in the rural areas of our LHIN. Patients may be put at risk if transfers are delayed or when coordination is not effective. Excellent outcomes have been experienced for hip fracture patients when the recommendations in the National Hip Fracture Toolkit (see Appendix E) are followed. The authors note that bed rest and lack of mobility results in the loss of muscle and bone mass. This patient population may have been unable to ambulate for a period of time as they waited for their surgery and, as such, mobilization and the facilitation of activity levels is crucial to their recovery. They recommend that patients be mobilized as soon as medically stable (within 12 to 24 hours). Thus it is essential that mechanisms be put in place to ensure that transfers and repatriation are timely. In addition, direct healthcare system costs are less when patients are discharged home versus those transitioned to long-term care. The Strategic partnership of Canadian Orthopaedic Care Strategy Group concluded:

In 1996/97 the annual costs to care for hip fracture patients was estimated at 650 million dollars. With the current aging population, by 2041 the economic burden is expected to rise to 2.4 billion annually. Direct healthcare system costs are approximately $27,000 per patient; with costs as low as $21,000 for patients discharged home, and as high as $47,000 for those transitioned to long-term care. (Bone and Joint Network, (June 30 2011), National Hip Fracture Toolkit, 7)


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Maintaining patient function so that they are able to return home whenever possible is a key consideration in coordinating care for non-elective and trauma patients to improve both patient outcome and system sustainability. Thus, it is recommended that the relationships between Central East LHIN institutions be formalized to ensure high-quality and timely care for non-elective and trauma patients.

Implementation Activity Responsible Estimated Time Draft a Memorandum of Understanding in regards to orthopaedic non-elective and trauma patients in conjunction with IOCP implementation*

RSTG/ OSTG/LHIN Mid-term

Implement changes TBD Mid-term Develop performance indicators RSTG/ OSTG/LHIN Mid-term Monitor service provision TBD Mid-term Share practices and outcomes Rehab Group Mid-term Identify enhancements that can be made Rehab Group Mid-term

*Based on best practices established the National Hip Fracture Toolkit, Onta rio’s Life and Limb Policy and CritiCall procedures.

Key Objectives Continue to provide high-quality accessible care to those patients

who really need it Monitor to ensure that increasing demand is met Equal and timely access to patients across the LHIN A coordinated approach is in the best interests of the patient and the

system Integrated and evidenced based therapy Effective use of available health care resources Sustain existing improvements

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Process Reviews and Quality Improvements Recommendation #3: Review processes within fracture clinics to identify opportunities for quality improvements, standardization, and health human resource utilization.

Rationale

Fracture clinics are the ‘catch all’ for orthopedic and plastic surgery injuries, post-operative follow-up appointments and often pre-operative consults as well. Their function greatly improves throughput and flow of the patients with these injuries from the ED. However, fracture clinics themselves have not been reviewed for improvements in standard work and processes improvements in the same manner and with the same attention paid to the ED, or operating rooms, or even discharge processes from inpatient care units. As discussed in the Current State section, providers in the Central East LHIN have had noteworthy success with quality improvement initiatives. Fracture clinics were identified as an area with a range of quality improvement opportunities, from process improvements to utilization of health human resources. Applying business strategies and processes that are used in other out-patient clinics and in other LHINs’ standard fracture clinic processes will help to increase system capacity while maximizing health human resource utilization. Rehabilitation professionals provide important services in fracture clinics and appropriate utilization of these resources can improve patient flow. However, rehab professionals’ activity in fracture clinic varies across the LHIN and the benefits of their presence is not fully realized. For example, some patient’s injuries may require a few minutes of education on home exercises that can be provided during their fracture clinic appointment, instead of the patient needing to make an additional appointment for physiotherapy later in the week. Additionally, at times schedules are created that do not utilize the time of these rehabilitation professionals to their full capacity. As part of the process review, it is recommended that human resource utilization, focusing on rehabilitation professionals, be reviewed. Cost effective scheduling practices can be shared among service providers where appropriate. A detailed process review will help clinics understand the end-to-end patient journey. This can then be used to identify quality improvements and efficiency gains.

Key Objectives Share quality and efficiency gains Improve patient experience and continuity of care Improve efficiency and system sustainability while reducing costs Avoid attendance in outpatient rehab

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Implementation Under this recommendation, implementation will be focused on the internal operations of those organizations with fracture clinics. Implementation should proceed in a way that is best suited to those organizations provided implementation is coordinated, best practices are shared and progress reports are made available.

Activity Responsible Estimated Time

Establish a fracture clinic working group RSTG Short-term Review high-level current state and identify best practices

Working Group Short-term

Initiate process reviews & implement quality improvements

Individual Organizations Mid-term

Standardize care based on process reviews Working Group Mid-term Monitor progress Working Group Mid-term Report progress to LHIN TBD Mid-term

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Setting Standards

Rationale for the Standardization of Care The management of patients through the health care system is extremely complex. This complexity can lead to delays in services and even errors. Standardization through the development of documentation such as care maps can increase performance by improving patient flow and ensuring that patients receive care that is based on evidence. Patient flow between units and organizations can also be facilitated by the creation of standard admission and discharge criteria and transfer processes. While each organization endeavors to provide the best care possible, there is no regional standardization in musculoskeletal rehab. There is standardization within individual organizations, however, patients entering the system in different locations are likely to receive different care. Patient equity across geographies is a goal of this planning exercise; and, there are, likely, best practices that can be shared to improve the quality of care, patient flow and efficiency. It is recognized that standardization may not always be practical or in the best interests of Central East LHIN patients. Thus, it is recommended that detailed exploration of best-practices be completed by rehab provider representatives and that standardization be implemented where it promotes cost-effectiveness, excellent patient experience and population health. Recommendation #4a: Standardize pre-surgical education content for hip and knee replacement and hip fracture patients based on evidenced best-practice throughout the LHIN.

Rationale A number of excellent patient education programs have been implemented in the Central East LHIN. As noted in the Current State section, all surgical hospitals have implemented some sort of pre-surgical education program for their hip and knee replacement and hip fracture patients. These programs help to manage patient and family expectations with respect to post-surgical care, as well as prepare patients for their return home. Pre-surgical education programs are a major reason that Central East LHIN hospitals have been able to meet or exceed length-of-stay and discharge home targets for their hip and knee replacement patients (See Figure 7 above). As a result, the Rehab Services Task Group believes that sharing information, leveraging each other’s best practices and standardizing the content and key messages of pre-surgical patient education could have great benefits for patients and health service providers. Due to the diversity of the population living in the Central East LHIN, patient information may be provided in different languages or formats. These resources should be shared between hospitals to provide consistency as well as decreasing the costs associated with services such as translation. It is anticipated that implementation of this recommendation will improve the patient experience as informal feedback suggests that patient satisfaction with these programs can be quite high. It is also hoped that the standardization of pre-surgical education will enhance patient experience by improving consistency and continuity of post-surgical care. Standardization of pre-surgical educational content across the Central East LHIN and addressing local variations in care, would allow patients to attend education sessions closer to home while receiving surgery in a location that is further away from where they live.

Key Objectives Continue to meet and exceed provincial targets Implement evidence based best-practices Leverage each other’s best-practices, share quality and efficiency

gains Improve patient experience

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Implementation Because this recommendation seeks to standardize care across the Central East LHIN, implementation will be done by a regional group.

Activity Responsible Estimated Time Establish a Rehab Best Practices and Standardization Working Group

RSTG Short-term

Best practices sharing, literature review and environmental scan

Working Group

Short-term

Design standardized content for pre-surgical education Working Group Short-term Undertake stakeholder engagement Impacted HSPs and


Implement and monitor changes Mid-term

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Recommendation #4b: Standardize rehab care for hip and knee replacement and hip fracture patients based on evidenced best-practice, expert opinion and surgical protocol throughout the LHIN through coordinated care plans.

Rationale As mention above, many best-practices around hip and knee replacements have been implemented across the Central East LHIN. However, there is currently a lack of standardization for hip and knee replacement and hip fracture care pathways and rehab. Well established evidence demonstrates best practices for the rehab of these patients. As a result, the GTA Rehab Network is currently developing and implementing patient care pathways for hip and knee replacements. Central East LHIN service providers that participate in the GTA Rehab Network are expected to implement these care pathways. Those providers that do not participate in the GTA Rehab Network will be informed of these care pathways and encouraged to integrate them into their work with these patients. This work can be leveraged by service providers across the Central East LHIN to form the foundation for the standardization of care for these patient populations (See Appendix C for examples). Other work that can support standardization has been completed by the Workplace Safety and Insurance Board and Health Quality Ontario. This can be utilized by service providers to standardize care in a way that will be cost-effective. The care pathways developed by the GTA Rehab Network specific to total knee replacements and total hip replacements provide an evidence based framework for clinicians. These care pathways identify the type of post-operative rehabilitation best for the patient, for example class format versus one-to one therapy, as well as anticipated number of visits required to achieve well established patient outcomes. As well, criteria for referring to CCAC are included. Using these care pathways will result in quality and efficiency gains for all organizations and can be shared for these high-volume procedures. The standardization of admission criteria will allow individuals to access the most appropriate and efficient modality of care. This standardization should result in a larger number of patients receiving care on an ambulatory basis, thus lowering costs and allowing for reinvestment in additional front-line services. As a result, regional capacity will be expanded. 7-day a week therapy should also be explored as hospitals will be more competitive employers if all offer 7-day a week therapy. As well, by ensuring that patients across the LHIN are receiving similar care, access will be equalized and patients’ transitions should occur more smoothly, improving patient experience.

Key Objectives Implement evidence best-practices Leverage provincial work Share quality and efficiency gains Equity of access across the LHIN Improve transitions in care and patient experience

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Implementation Activity Responsible Estimated Time Establish Working Group RSTG Short-term Best practices literature review and environmental scan*


Design standardized care maps including: • Screening and prioritization criteria • Timing of care provision • Discharge checklists • Performance targets


Undertake stakeholder engagement Impacted HSPs and Working Group

Short-term

Implement and monitor changes Mid-term *leverage work completed by GTA Reha b Network, WSIB, HQO etc.

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Recommendation #4c: Review Hand Programs and based on that review standardize care for appropriate patient populations.

Rationale As mentioned in the Current State Section, there are hand programs at The Scarborough Hospital, Rouge Valley Health System, Lakeridge Health and Peterborough Regional Health Centre. These programs can serve patients that have received surgery or will be receiving surgery from an orthopaedic and/or plastic surgery, as well as post-injury rehab or prevention therapy. Because plastic surgeon specialists were not at the table it was felt that the group would benefit from a detailed review of those programs prior to discussing how to go about standardizing rehab care. As a result, the RSTG is recommending that a review of these programs be undertaken with the goal of standardizing care where possible, and that all relevant stakeholders be involved. The review will help us better understand the context and practices related to hand therapy. For example, a 1.0 full time equivalent (FTE) certified hand therapist may be providing care which can encompass the same care provided by a 0.5 FTE Occupational Therapist and a 0.5 FTE physiotherapist. At this time, there is no operational definition that clarifies what exactly a hand program provides. It could be as little as attendances at a fracture clinic to address upper extremity needs, or a full clinic with OT, PT, rehab assistants and clerical staff that see volumes from across the LHIN. Through the review, service providers will have an opportunity to share best practices as determined by practicing experts in the field. Once the programs and patient flow is well understood, patient populations for which there are evidenced best-practices can be identified and standard patient care maps can be developed. Care for the most appropriate patient populations may be standardized resulting in more equal access. Importantly, with greater standardization it will be the easier to transition patients to other partners and, when possible, closer to home thereby improving patient experience.

Key Objectives Share best practices Improved equity of access Improve transitions in care and patient experience

Implementation Activity Responsible Estimated Time Establish Working Group RSTG Mid-term Review hand programs at LH, RVHS and TSH

Working Group Mid-term

Identify patient groups for which there are established best-practices


Design standardized programs for those patient groups



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Recommendation #4d: Standardize rehab care and improve quality for other orthopaedic procedures based on evidenced best-practice, expert opinion and surgical protocol throughout the LHIN through coordinated care plans.

Rationale Although, much work has been done to establish evidenced-based best practice for hip and knee replacement and hip fracture patients, this is not necessarily the case for other orthopaedic patient populations. It was felt that establishing standardized care would not necessarily be appropriate for all patient populations and that for many of these patients their care would be more complex. In preparation for future QBPs it would be beneficial for providers to understand the services offered across the LHIN and identify quality and efficiency improvements. As a result, developing regional coordinated care plans for patient populations when it makes sense is recommended. Only when appropriate standardization can be identified should it be implemented, and the resources used to identify that pathways will be broader. Evidenced best-practices will be leveraged where they exist, but expert opinion and current surgical protocol will also form an important part of standardizing care for some orthopaedic patient populations. Standardized surgical protocol would assist in standardizing the post-operative rehabilitation required. Doing this will allow Central East LHIN rehab providers to realize similar benefits as standardization for high-volume patient populations. Best practices can be shared, enhancing the quality of care and efficiency throughout the LHIN. As well, rehab providers throughout the Central East LHIN should be encouraged to share their innovative strategies and associated patients’ outcomes. Access will be equalized as more patients will be receiving similar care across the LHIN. Partners will be able to transition patients more smoothly as care is increasingly standardized, resulting in improved patient experience.

Key Objectives Share quality and efficiency gains Equal access across the LHIN Improve transitions in care and patient experience

Implementation Activity Responsible Estimated Time Establish Working Group RSTG Mid-term Best practices literature review and environmental scan

Working Group

Mid-term

Design standardized care maps etc. Working Group Mid-term Undertake stakeholder engagement Impacted HSPs and



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Promoting Ongoing Quality Improvement and Innovation Recommendation #5: Continue to support innovative practices and testing to improve the quality of care.

Rationale As discussed in a number of the recommendations above, care should be standardized when there are established best practices or when it will enhance patient experience and cost-effectiveness. However, standardization should not inhibit opportunities to explore innovations that endeavor to improve care, in a fiscally responsible manner. Rather, research of innovations should be encouraged, funded, evaluated, and shared. Support for well-planned methodologically sound research that is grounded in improving value for money, population health, patient experience should be made available so that organizations have an incentive to explore these opportunities. Exploring innovative practices poses some risk for organizations. The work may be costly and it may not result in improvements; however, the exploration of innovation will improve system sustainability over the long-run and even evaluations that demonstrate the lack of success of an innovation can provide valuable information. Thus, providing incentives to evaluate innovations is a key recommendation of the Rehab Services Task Group.

For example, standardizing pre-surgical education is a recommendation that has been made by the RSTG. However, it is clear that further investigation of prehab is warranted. Rouge Valley Health System plans to conduct a pilot to evaluate the effectiveness of the prehab program and contribute to this limited body of research. Prehab at Rouge Valley Health System is a comprehensive program for elective hip and knee patients encompassing: pre-surgical education, exercise therapy, guided self-conditioning, goal setting and home preparation. Thus far, there is preliminary evidence that prehab improves patient satisfaction and reduces length of stay. Moving forward Physiotherapy outcome measures will be integrated into the program to compare the patient’s pre- and post-program physical condition and include: TUG (time up and go test); LEFS (lower extremity functional scale); and range of motion (both passive and active).

The Rouge Valley Health System model is based on the Beth Isreal Deaconess Medical Center model, but Rouge Valley Health System has taken it a step further to include a focus on patient engagement through setting and tracking SMART goals. The Beth Isreal Deaconess Medical Center completed a study of the prehab program and found improvements in patient reported measures, performance measures and other measures, such as length of stay, discharge location, amount and type of pain medication, timed up and go tests and the Functional scale of the Western Ontario and McMaster Universities Orthopedic Index (WOMAC).

The prehab program has shown positive outcome measures at the Beth Isreal Deaconess Center and is showing positive outcomes at Rouge Valley Health System. Further research of the program will help illustrate the impact of the prehab program. Thus, it is important that service providers in the Central East LHIN continue to have the flexibility to explore this kind of innovation. Ongoing support by rehab providers for innovations will help to continue to improve system capacity.

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Key Objectives Take advantage of new findings and continue to improve

performance, patient experience and cost-effectiveness

Implementation

Activity Responsible Estimated Time Explore funding opportunities Providers/ LHIN Short-term Establish a Regional Rehab Quality Improvement Committee

RSTG Mid-term

Monitor/evaluate initiatives Committee On-going

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Improving Data Collection and Performance Monitoring Recommendation #6: Review information requirements and standardize data collection across sectors to support improvements in access and quality of care.

Rationale The complexity of rehab service provision poses challenges for data collection and performance monitoring. As mentioned above patients may receive rehab in a variety of settings including:

• In the hospital sector on an inpatient basis in a Rehab Bed, a CCC Bed or an Acute Care Bed • In the hospital sector on an outpatient basis • OHIP-funded physiotherapy clinics • Community-based clinics/ programs • In long-term care homes • In their own home through the CCAC • Private clinics

An understanding of patient care and transitions across these settings is needed. Some standardization of reporting has begun (See Figure 12 below) and can be improved utilizing the MIS System or the OHRS.

Figure 12: MIS Rehabilitation and CCC reporting codes 7218110 IP Medical Rehabilitation 7128130 IP Rehabilitation – Combined 7129520 IP LTC – Complex Continuing Care

Many of these organizations collect data about the services provided and the clients that are served. However, this data is not shared across sectors. Indeed, often data is not even compatible across sectors. In addition, some organizations are unable to establish a comprehensive view of the rehab services provided. For example, the rehab services provided in Acute Care beds and Complex Continuing Care beds is not always tracked and if it is it may not be reported or published (as demonstrated by Figure 9 above). The volume of outpatient visits at ambulatory clinics is not reported at a LHIN level. Overall, the data that is available cannot provide insight into whether patients are receiving the most appropriate care, or whether access is standardized and equitable. It is not possible to track all rehab services that a patient receives; and as a result, patients’ journeys from pre-surgical care to the completion of rehab is not well understood. It may not be known to all parties, for example, that a patient is receiving care both through the CCAC and in an outpatient clinic. Funding challenges can arise from this lack of data, and it also limits service planning. The overall volumes of services provided in the Central East LHIN, and thus the gap between supply and demand, is unknown. The lack of service volume data poses an obvious barrier to regional capacity planning. Performance data can indicate where capacity is needed. However, little performance data is collected. Performance data beyond the Orthopaedic Quality Scorecard (see Figure 7 above) is not published. As a result, it is not possible to determine where performance requires attention, or where it has improved. Quality and efficiency are not easily assessed; and, it is difficult to demonstrate the value of implementing best practices, or evaluate innovations. Standardized data collection across sectors would allow HSPs and the Central East LHIN to better understand the current services levels and patient need for rehab. Simply, collecting the volumes of patients served across the LHIN in a variety of settings would allow for improved capacity planning. To coordinate services regionally, it is necessary to have a solid understanding of the volume of rehab services that are provided. Tracking patient flow

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would also help HSPs to understand where there are redundancies, or where patients are not receiving the most appropriate care. As funding models continue to become more patient-centric and funding begins to “follows the patient” understanding patient flow will become all the more important. It will be necessary to understand patient flow to take advantage of these funding models. Performance indicators will help service providers to identify initiatives that will enhance the quality and efficiency of rehab services, and promote sharing of best practices. There would be great benefit for the Central East LHIN in shared data standards and collection across LHINs, particularly as there is a proportion of patients who receive surgery in other LHINs and return to the Central East LHIN for rehab. However, this is beyond of scope of the mandate of the Central East Rehab Services Task Group.

Key Objectives Improved regional capacity planning Improved understanding of patient flow so that in the future funding

can follow the patient Ability to measure performance improvements in all sectors Availability of data to inform innovations and improvements in care

Implementation Activity Responsible Estimated Time Establish a Working Group RSTG/ Regional Decision

Support Committee Mid-term

Building on work done by the GTA rehab network, identify required performance indicators Establish data collection requirements


Establish systems to be used Working Group/ Regional IT/ IM Group

Mid-term

Implementation planning Working Group/ Regional IT/ IM Group

Long-term

Undertake stakeholder engagement Impacted HSPs and Working Group

Long-term

Implement and report Long-term

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Enhancing Preventative Care Recommendation #7: Review services and recommend preventative programming for the Central East LHIN.

Rationale One third of adults over age 65 fall at least once per year. Falling can cause injury such as hip fractures, loss of mobility and independence. Demand for orthopaedic procedures secondary to injury can be reduced through preventative programming to reduce incidence and risk of falling. As mentioned above, many community organizations offer fall prevention programming and osteoporosis education within the Central East LHIN. A comprehensive picture of these prevention programs, as well as other preventative services, does not currently exist. Establishing an inventory of programs which focus on fall prevention and osteoporosis education would be beneficial for service planning and for patient care. This will be facilitated by the implementation of recently announced funding for falls prevention and exercise classes. Patients could self-refer to these programs and providers could broaden their referrals knowing primary prevention lessens the need for secondary intervention. Improving transitions in care to preventative care in the community should be a key focus of implementation. Programming is recommended to be provided locally reaching as many seniors as possible in both the community, and in institutional settings. In addition, partnerships that smooth transitions in care from rehab to preventative care and vise-versa can help patients to stay healthier and in their own home longer. Linkages with other aspects of seniors’ care, such as the GAIN strategy and newly emerging Health Links, could be formalized so that rehab and preventative care become central aspects of an entire continuum of care. Other possible partners include pharmaceutical companies that provide public education and knowledge translation education to professionals, patients and their families. These programs provide important preventative and assessment services. Formal partnerships would result in robust preventative care programming, reducing the demand for orthopaedic surgical care and rehab. Robust primary and secondary preventative programming can help to prolong the time that patients are able to remain in their own homes and communities, thus reducing the overall healthcare resources that those clients require and improving patient experience at the same time.

Key Objectives Reduce readmissions Improve population health Improve patient experience

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Implementation It is recommended that implementation planning be completed at a cluster or local level as a local understanding of services is needed. Implementation strategies for this recommendation should be aligned with Health Links and any reform of the GAIN strategy. Activity Responsible Estimated Time Develop inventory of falls prevention, exercise classes and other preventative programs in the Central East LHIN

LHIN/ Working Group Short-term

Publish inventory TBD Short-term Establish Working Group to identify coordination opportunities with GAIN/RSGS

RSTG/ LHIN Short-term

Information sharing/gap analysis Working Group Short-term Develop recommendations Working Group Short-term Implement changes Working Group Short-term

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Implementation Suggested implementation activities were outlined for each recommendation above. For the most part, it is recommended that implementation planning be done with partners across the LHIN as standardization of care is needed. Certain cluster or locally based activities were identified within relevant recommendations. Planning for recommendation #1, which speaks to siting and sizing, could be done by cluster as need varies within each cluster. Recommendation #7, preventative care, could also to be implemented at the cluster level to ensure that care meets local needs and that transitions in care are improved. Recommendation #3, quality improvement initiatives in hand programs, should be largely implemented by hospitals with those programs. A regional review of improvements made should follow and any resulting standardization should be aligned with the IOCP implementation strategy. There are several dependencies among activities. For example, standardized care maps for high-volume patient populations will influence siting and sizing for inpatient, outpatient, community-based and in-home rehab. Also, there are a number of initiatives underway that should be implemented in conjunction with the recommendations above to reduce the redundancy of work and ensure that initiatives have a positive impact (See Figure 13 below). For example, Resource Matching & Referral will influence work done around standardizing care pathways and these two initiatives should leverage each other’s work. Ongoing physiotherapy reform, and the future implementation of the stroke QBP, will have a big impact on siting and sizing. Other capacity planning initiatives, including the IOCP, will impact siting and sizing as well. Improving rehabilitative care for patients following a trauma will be influenced by the work done to implement the IOCP as well as other policies and agreements regarding trauma patients. The Rehabilitative Care Alliance has included developing a comprehensive, standardized minimum dataset for Ministry-funded outpatient/ambulatory rehabilitative programs in its work plan over the next two years. This work could be done in conjunction with Recommendation #6, standardizing data collection.

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Figure 13: Concurrent Initiatives

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The implementation strategy, recommended by the RSTG, is to begin with initiatives that are quick-wins, those that are both easy to implement and have a high-impact. A number of recommendations are expected to be easily implementable and have a high-impact. Those initiatives are outlined below in a PICK (Possible, Implement, Challenge, Kill) Chart (see Figure 14). For example, standardizing pre-surgical hip and knee education is thought to be easily implementable because there is a large degree of similarity. Also, this could have a large impact on patient experience and access because patients could then access hip and knee schools at any location in the Central East LHIN, obtaining care as close to home as possible. Much of the work for standardizing care pathways for total joint replacements and hip fractures has been done by bodies such as the GTA Rehab Network. With broad support for similar recommendations made in the IOCP and clear evidence-based practices, this recommendation should be relatively easy to implement. The impact is high because standardization can help to expand system capacity as discussed above. Supporting innovation has a lower impact than other recommendations because of the inherent risk involved in exploring unproven practices. However, continuing and enhancing support for innovation is not particularly challenging and it is likely that some innovations will be highly beneficial, thus it is strongly recommended. Work is already being done around preventative care, thus the impact is lower than other recommendations. The challenge around preventative care is in ensuring that patients have access to these services because of the sheer number and complexity of providers, as well as challenges in creating smooth transitions in patient care. Partnering with other programs and initiatives, such as the GAIN strategy, can reduce the complexity involved in improving access to preventative care. As physiotherapy is reformed across the province the ease and impact of improving access to outpatient care will evolve. Siting and sizing to ensure equity of access will be heavily influenced by this work. Hospitals with hand clinics have significant experience with Quality Improvement initiatives and, as mentioned above, these initiatives have had a great deal of success in helping hospitals do more with less. However, these initiatives are time-consuming and garnering physician support could be challenging. It is recommended that implementation of difficult-to-implement initiatives follow implementation of quick-wins. This will allow implementation to have the greatest impact over time. Implementing regional trauma programs and agreements has been challenging in the past. Also, the vast majority of patients are being treated appropriately. Ongoing initiatives such as the implementation of the provincial Life and Limb Policy will support implementation of this recommendation. The standardization of care pathways for other orthopaedic populations is more challenging than it is for total joint replacement and hip fracture patients because there is not well established evidenced best-practice. Reviewing and standardizing hand clinics would require a robust physician engagement process to ensuring their buy-in as care is driven largely by physician protocol. The lack of stakeholder buy-in is a risk that is somewhat mitigated by the momentum of the IOCP, however extensive stakeholder engagement and input is required. While standardizing data within hospitals can be supported by systems that are already in place creating data standards across sectors will be more challenging. Understanding the care provided in private clinics is beyond the scope of review, however the impact of private clinics should be considered in future capacity planning. However, establishing data standards to facilitate capacity planning and transitions in care will have a large impact on the quality of care and patient experience. Without standardized data collection understanding of population need across the Central East LHIN is opaque and dialogue regarding regional programming is compromised. Discussed action items that had low impact (i.e. those in the “POSSIBLE” quadrant) and those that were difficult to implement and had a low impact (i.e. those that fell in the “KILL” quadrant) were not recommended in this report.

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Figure 14: PICK Chart

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Conclusion The recommendations contained in this report, in conjunction with the IOCP, seek to improve patient access and experience, the quality of care, and value-for-money in rehabilitative services. The recommended initiatives are expected to have a great impact on patients, and promote the values of rehabilitative care providers. Addressing the lack of outpatient clinics in the North East cluster and ensuring that patients can obtain rehab as close to home as possible will promote better patient access. Improved coordination for trauma and non-elective patients will enhance the quality of care those patients receive. Quality improvement in fracture clinics is expected to result in more efficient services provision and enhanced capacity. Standardization of care pathways will improve patient experience in addition to promoting service efficiency. Innovations that seek to improve patient experience, quality and value-for-money could receive a greater focus. Standardized data collection across sectors would enhance future capacity planning as well as facilitate transitions in care. Finally, preventative programming will help patients stay healthier in their own homes and communities. The successful implementation of these recommendations will be facilitated by partnerships with ongoing initiatives as well as other providers that can support rehab.


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Appendices

Appendix A: Rehab Service Task Group Membership Representative Organization Position Deb Galet, Co-Chair Lakeridge Health Director PASS (Post-Acute Specialty Services) Karl Wong, , Co-Chair Rouge Valley Health System Director Post Acute Care Glyn Boatswain Rouge Valley Health System Regional Manager Cardiac and Cancer Program Jeff Hohenkerk Rouge Valley Health System Chair, LHIN Diagnostic Imaging Group Tom Jackson The Scarborough Hospital Patient Care Director for Diagnostic Services Jennifer Istvan The Scarborough Hospital Manager, Interprofessional Practice Barb Huggins Peterborough Regional Health Centre Manager , A2 Rehabilitation Unit Shailesh Nadkarni

Peterborough Regional Health Centre Director, Mental Health. Sub Acute Care & Seniors Health

Gabrielle Sadler Ross Memorial Hospital Manger Continuing Care Program Ann Wehrstein Ross Memorial Hospital Director for Surgical, Woman & Child Jan Raine Campbellford Memorial Hospital Chief Nursing Officer Debbie Watson Haliburton Highlands Health Services Manager of Patient Care Joan Scott Northumberland Hills Hospital Program Director Post Acute Specialty Services Marika Beaumont Northumberland Hills Hospital Professional Practice Leader, OT Margot Fitzpatrick Community Care City of Kawartha Lakes Clinical Program Manager Lydia Rybenko Port Hope Community Health Centre Nurse Practitioner and Clinical Manager Jean Kish CECCAC Director, Client Services Brian Laundry CE LHIN Lead (QI & Evaluation) Laura Wise CE LHIN Planner Adam Erwood CE LHIN Planner Chad Gyorfi CE LHIN Senior Finance Consultant

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Appendix B: CMGs included in “Orthopaedic Care” (300) JOINT REPLACEMENT WITH MALIGNANT NEOPLASM (301) BACK/NECK INTERVENTION WITH MALIGNANT NEOPLASM (302) LOWER LIMB INTERVENTION WITH FLAP/GRAFT WITH MALIGNANT NEOPLASM (303) FIXATION OF LOWER LIMB WITH MALIGNANT NEOPLASM (304) OTHER LOWER LIMB INTERVENTION WITH MALIGNANT NEOPLASM (305) CRANIOFACIAL BONE INTERVENTION WITH MALIGNANT NEOPLASM (306) UPPER LIMB INTERVENTION WITH FLAP/GRAFT WITH MALIGNANT NEOPLASM (307) OTHER UPPER LIMB INTERVENTION WITH MALIGNANT NEOPLASM (308) OTHER MUSCULOSKELETAL INTERVENTION WITH MALIGNANT NEOPLASM (312) C1/C2/THORACIC SPINE INTERVENTION (313) SPINAL VERTEBRAE INTERVENTION (314) OTHER INTERVENTION ON BACK/NECK (315) BILATERAL HIP/KNEE REPLACEMENT (316) REVISED HIP REPLACEMENT WITH INFECTION (317) REVISED HIP REPLACEMENT WITHOUT INFECTION (318) REVISED KNEE REPLACEMENT WITH INFECTION (319) REVISED KNEE REPLACEMENT WITHOUT INFECTION (320) UNILATERAL HIP REPLACEMENT (321) UNILATERAL KNEE REPLACEMENT (322) OPEN KNEE INTERVENTION EXCEPT FIXATION WITH INFECTION (323) OPEN KNEE INTERVENTION EXCEPT FIXATION WITHOUT INFECTION (325) CLOSED KNEE INTERVENTION EXCEPT FIXATION WITHOUT INFECTION (326) SHOULDER REPLACEMENT (328) RESECTION/AMPUTATION OF PELVIS/LEG WITH INFECTION (329) RESECTION/AMPUTATION OF PELVIS/LEG WITHOUT INFECTION (330) FIXATION OF LOWER LIMB EXCEPT ANKLE/FOOT (331) OSTEOTOMY OF LOWER LIMB EXCEPT FOOT (332) OTHER REPAIR BONE OF LEG EXCEPT ANKLE/FOOT (333) MAJOR FOOT INTERVENTION EXCEPT SOFT TISSUE WITH INFECTION (334) MAJOR FOOT INTERVENTION EXCEPT SOFT TISSUE WITHOUT INFECTION (335) OTHER FOOT INTERVENTION, EXCEPT SOFT TISSUE (336) RESECTION/AMPUTATION/FIXATION OF UPPER LIMB EXCEPT SHOULDER/HAND (337) HAND INTERVENTION (338) OSTEOTOMY OF UPPER LIMB EXCEPT HAND (339) OTHER UPPER LIMB INTERVENTION EXCEPT HAND (340) ELBOW INTERVENTION (341) SHOULDER/ROTATOR CUFF INTERVENTION (342) BIOPSY/INVASIVE INSPECTION OF BONE (343) OTHER MUSCULOSKELETAL INTERVENTION EXCEPT SOFT TISSUE (344) SOFT TISSUE INTERVENTION OF UPPER LIMB (345) SOFT TISSUE INTERVENTION OF LOWER LIMB (346) OTHER MUSCULOSKELETAL SOFT TISSUE INTERVENTION (347) CRANIOFACIAL BONE INTERVENTION WITH MUSCULOSKELETAL DIAGNOSIS (349) NERVE INTERVENTION WITH MUSCULOSKELETAL DIAGNOSIS (357) MUSCULOSKELETAL MALIGNANT NEOPLASM (358) PATHOLOGICAL FRACTURE

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(359) OSTEOMYELITIS/SEPTIC ARTHRITIS (360) VERTEBRAL/DISC DISEASE (361) SYSTEMIC CONNECTIVE TISSUE DISORDER (362) ARTHRITIS (363) OTHER SOFT TISSUE DISORDER (364) BACK PAIN/STRAIN (365) PAIN/STIFFNESS, EXCEPT BACK (366) OTHER MUSCULOSKELETAL DISORDER (367) OTHER SYNDROME/DEFORMITY (368) ORTHOPEDIC AFTERCARE (369) STRAIN/SPRAIN/JOINT/TENDON DISORDER (438) DEHYDRATION (726) HIP REPLACEMENT WITH TRAUMA/COMPLICATION OF TREATMENT (727) FIXATION/REPAIR HIP/FEMUR (728) OTHER INTERVENTION ON HIP/LOWER LIMB WITH TRAUMA/COMPLICATION OF TREATMENT (729) REPLACEMENT/FIXATION/REPAIR OF TIBIA/FIBULA/KNEE (730) OTHER MAJOR BONE INTERVENTION WITH TRAUMA/COMPLICATION OF TREATMENT (731) SPINAL INTERVENTION WITH TRAUMA/COMPLICATION OF TREATMENT (738) FIXATION/REPAIR OF SHOULDER JOINT (739) REDUCTION/FIXATION/REPAIR UPPER BODY/LIMB EXCEPT FIXATION/REPAIR OF SHOULDER (743) OTHER INTERVENTION ON BONE OF UPPER BODY WITH TRAUMA/COMPLICATION OF TREATMENT (744) MUSCLE/TENDON/MINOR JOINT INTERVENTION WITH TRAUMA/COMPLICATION OF TREATMENT, LOWER LIMB (746) REDUCTION LOWER LIMB EXCEPT ANKLE/FOOT (747) REDUCTION/FIXATION/REPAIR OF ANKLE/FOOT (750) MUSCLE/TENDON/MINOR JOINT INTERVENTION WITH TRAUMA/COMPLICATION OF TREATMENT, UPPER LIMB (766) FRACTURE OF FEMUR (767) OTHER FRACTURE DISLOCATION OF LEG (768) FRACTURE OF PATELLA/UPPER TIBIA/FIBULA (769) FRACTURE OF SHOULDER/UPPER HUMERUS (770) OTHER FRACTURE/DISLOCATION OF ARM/SHOULDER (771) SPINAL INJURY (772) RIB FRACTURE/FLAIL CHEST (777) OTHER/UNSPECIFIED FRACTURE/DISLOCATION (783) FRACTURE/DISLOCATION OF WRIST/HAND/ANKLE/FOOT

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Appendix C: Outpatient Volumes 2012/2013

The Scarborough Hospital Volume Measure Data Notes 15,311 visits Musculoskeletal patients only. Data was not included by site as

the two sites are integrating. 1, 487 patients Collected on a best efforts basis as quality of this indicator is low.

Musculoskeletal patients only. Data was not included by site as the two sites are integrating.

Rouge Valley Health System Patient Type Site Volume (attendances) Data Notes Fracture Clinic RVA 17,754 Fracture Clinic RVC 14,849 Hand Clinic RVA 2,915 Hand Clinic RVC 4,373 MSK Orthopaedics RVA 6,008 MSK Orthopaedics RVC 5,287 Pediatric Orthopaedics RVC 712 All diagnosis RVA 26,677

All diagnosis RVC 25,221 Total 51,898

Lakeridge Health Inpatient and Outpatient

Site Volume (face to face attendances)

Volume (telephone attendances)

Data Notes

ARC LHW and Rossland Road

29,735 347 includes ARC-Neuro and MSK Physio at Rossland Road and LHW; excludes Nursing Visits

ARC-HAND Rossland Road

7,438 0 Hand Clinic

ARC LHB 13,013 20 includes inpatient and outpatient physiotherapy

ARC LHPP 6,834 6 includes inpatient and outpatient physiotherapy

Total 57, 020 373

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Lakeridge Health

Patient Type Site Patients Volume of initial visits*

Data Notes

ARC-Hand Rossland Road 724 5,279 ARC Rossland Road 657 7,599 Neuro Rehabilitation, Amp Clinic and MSK Physio. Does not include EMG, Spasticity, Stroke Follow up, Hands, or Resp. Rehab

LHW 58 703

Knee Classes and Balance Class

LHW 58 703 Outpatient only

Includes MSK Physio and a few neuro patients who required physiotherapy only close to their home

LHP 332 3,134

Knee Classes LHP 27 253 began capturing this metric part way through the year

Includes MSK Physio only and a few neuro patients who required physiotherapy only close to their home

LHB 277 3,049

Knee Classes LHB 59 850

Total 9,624 29,330

* Patients are registered by the clerks on their initial visit and attended by the therapists every session thereafter, so not all visits are ca ptured.

Peterborough Regional Health Centre

Patient Type Volume (attendance days) Data Notes Acute In-house Adult 705 PT Includes all face-to-face attendance for acute

inpatient, data is not collected by diagnosis. Clinic In-house Adult 16, 218 PT Includes all face-to-face attendance for clinical

inpatient, data is not collected by diagnosis. Outpatient Adult 36 PT Includes all face-to-face attendance for

outpatient, data is not collected by diagnosis. Clinic In-house Pediatrics 576 PT Includes all face-to-face attendance, data is not

collected by diagnosis. Clinic In-house Adult 2,880 OT Includes all face-to-face attendance for clinical

inpatient, data is not collected by diagnosis. Clinic In-house Pediatrics 144 OT

Includes all face-to-face attendance for clinical inpatient, data is not collected by diagnosis.

Total 20,559 Haliburton Highlands Health Services

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Volume Data Notes 2100 visits Includes all attendance, data is not collected by diagnosis. Data is

the average for 2011/12 and 2012/13. Due to recruitment challenges volumes declined over this period. In past years average visits were roughly 3000.

200 patients Includes all attendance, data is not collected by diagnosis. Data is the average for 2011/12 and 2012/13. Due to recruitment challenges volumes declined over this period. In past years average visits were roughly 300.

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Appendix D: GTA Rehab Network Patient Flow Maps

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Appendix E: National Hip Fracture Toolkit Exert “Bed rest and lack of mobility results in the loss of muscle and bone mass. This patient population may have been unable to ambulate for a period of time as they waited for their surgery and, as such, mobilization and the facilitation of activity levels is crucial to their recovery. As such, the following needs to be considered:

• Patients should be mobilized as soon as medically stable (i.e. within 12-24 hours of surgery). • Mobility can start with sitting/dangling in very frail patients but should progress to standing

within 24 hours of surgery. • Weight-bearing status should be ‘as tolerated’; if not, discuss with surgeon regarding

ambulation prognosis • Ambulation aids should be assessed and their use taught. Patients who are safe to

ambulate with the aid independently should have access to the aid to promote independence. • Ambulation status should be posted at the patient’s bedside (such as in a white board) to ensure

all staff are able to mobilize the patient appropriately. • Patients should receive at least daily physical and occupational therapy, including weekends,

regardless of cognitive status. • Rehabilitation sessions should focus on gait quality, walking endurance, transfers, activities of

daily living and safety. • Treatment goals should progress the patient’s ambulation, transfer, and activities of daily living

status. These goals should be set daily based on their pre-fracture capacity.”

Ref: (National Hip Fracture Toolkit, June 30, 2011. Pg 35)

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Appendix F: References Bone and Joint Canada. (June 30, 2011). National Hip Fracture Toolkit. http://boneandjointcanada.com/?sec_id=310&msid=3. Central East LHIN. (March 2013). Central East LHIN Integrated Orthopaedic Capacity Plan. http://www.centraleastlhin.on.ca/uploadedFiles/Home_Page/Board_of_Directors/Board_Meeting_Submenu/05.4_-_Ortho_Capacity_Plan_-_March_27_2013_Board_Meeting.pdf. Government of Ontario. (September 2012). Integrated Health Service Plan 2013 – 2016 Common Environmental Scan. http://www.centraleastlhin.on.ca/uploadedFiles/Home_Page/Integrated_Health_Service_Plan/Provincial_LHINs_Environmental_Scan_-_Technical_Document_September_2012.pdf Rooks, D.S. et al. (2006). Effect of Preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty. Arthritis & Rheumatism. 55 (5), 700-708. Swank, A. M. et al. (2011). Prehabilitation before total knee arthroplasty increases strength and function in older adults with severe osteoarthritis. Journal of Strength and Conditioning Research. 25 (2), 318-325.

http://boneandjointcanada.com/?sec_id=310&msid=3





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