Expanding Patient-Centred In-Home Physiotherapy Services
to Support a Range of Patient Needs and Goals
Central East CCAC
Mississauga Halton CCAC Central West CCAC
Physiotherapy Reform
The report, “Living Longer, Living Well” (Sinha 2012), promotes improved mobility for seniors to help them live safely and independently at home as long as possible. In response, the Ministry of Health and Long-Term Care launched an initiative to reform PT services including in-home PT services. • CCACs: $33 million in annualized funding to expand the
provision of in-home physiotherapy services to 60,000 seniors/other patients and clear the physiotherapy wait list
• Falls Prevention and Exercise Classes: $10 million to provide exercise and falls prevention classes
• Others: PT Clinics, Long Term Care Home and Primary Care Services
Transition from OHIP funded Physiotherapy Services
Initial Priorities during the Transition Period • Eliminating waiting lists for in-home physiotherapy. • Identifying and transitioning patients receiving OHIP-funded
physiotherapy (ended on August 21st, 2013). • Streaming to appropriate services
In-home physiotherapy Exercise classes Falls prevention Other services
Magnitude of the Transition CCACs and SPOs successfully collaborated to transition over 32,000 patients in over 1,000 sites across the province, bringing 23,300 on to care over a four month period.
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Goal-oriented Physiotherapy
Patients needing long-term support to maintain function
and prevent decline
Patients who really need PSS services
People who need referrals to other services (e.g., pain
management)
CSS Exercise Classes
People needing 1:1 help to access classes
CSS Falls Prevention
Assumptions prior to the transition
Additional needs
Physiotherapy Advisory Panel Recommendations
In June of 2013, an advisory panel was established to review the literature and recommend evidence-informed practices to support the development of new,
patient-centred models of care.
• Led by Cathy Hecimovich (CEO of Central West CCAC), membership included experts from geriatrics, the rehabilitation sector and the physiotherapy profession along with CCAC and OACCAC representatives.
• Recommended a number of evidence-informed innovations including: • support for an expansion of PT scope of practice in home care, • integration of physiotherapist support personnel, • focus on outcome-focused service delivery to serve the needs of different in-home
physiotherapy patient groupings, • self-management models.
To operationalize the recommendations and support the needs of this new population, a provincial working group came together to develop the
PT service delivery model of care.
In-Home Physiotherapy Service Delivery Model
In-Home Physiotherapy
Stream 3: Maintenance Goal: Maintain & Prevent
Decline in Function
Stream 2: Restorative Goal: Restore Optimal
Function
Stream 1: Rehabilitation Goal: Improve & Restore
Independent Function
Patient-Centred, Evidence-Informed Care
• Operationalization of the model of care for PT: • expands the capacity of in-home PT service delivery to address a range of
patient needs and goals (rehabilitation, restorative and maintenance). • reinforces outcome-focused care delivery. • brings province-wide consistency to the delivery of in-home physiotherapy
services while allowing for local variation. • enables the health care system to better support seniors to live as safely and
independently as possible.
• Ongoing work: • CCAC sites continue to engage locally with SPOs and retirement home
operators to operationalize the recommendations. • OACCAC and CCACs continue to engage with provincial associations: ORCA,
OCSA, OHCA, APACTS. • Implementation and testing continues: based on local needs and conditions,
each CCAC is choosing to implement recommendations according to those needs.
Site Perspectives
Physiotherapy Reform and Physiotherapy Transition in Central East CCAC
Laszlo Cifra Program Director, Integrated
Care, CE CCAC
Michelle Nurse Director, Contracts and
Relationships, CE CCAC
Implementing the New Physiotherapy Model: Successes, Challenges & Key Learnings in
Mississauga Halton CCAC
Carey Lucki Program Manager, Patient Care,
MH CCAC
Physiotherapy and Exercise and Falls Prevention Program in Central West CCAC
Kimberley Floyd Director of Client Services,
CW CCAC
Physiotherapy Reform and Physiotherapy Transition
Phase 1, 2 and 3
Central East CCAC
Our Task
• “Soft Landing” for patients • Transitioning of 4000 Patients from
Designated Physiotherapy Clinics (DPC) to CCAC
• Ensuring Service Provider human resource capacity
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Phase I - Approach
• Initiation of a Physiotherapy Steering Committee • Seconded an Internal Physiotherapist to provide
expert advice to the steering committee • Early engagement of Service Provider Organizations
(SPO) • Early engagement of Retirement Homes (RH) and
Congregate Setting Administrators • Introduction of Physiotherapy Assistants (PTA’s)
early in the transition
11
Phase I - Approach, cont’d • Obtained patient lists from RH’s and existing
DPC providers • Assigned patients to SPO based on pre-
determined cluster care assignments • SPO assessment completed for each patient • Received recommendations from SPO
regarding patient’s transition plan – exercise and falls prevention classes – continue with restorative care (up to 8
weeks) 12
Phase I - Approach, cont’d
• Registered all patients in CHRIS • Authorized services based on the SPO
recommendation
13
Phase I - Results, cont’d
Physiotherapy Reform Statistics • 3972 patients received from the DPCs and
registered with CECCAC • 3290 patients received treatment from
CECCAC • 2270 referrals to exercise and Falls
Prevention Programs • 104 patients removed from Physiotherapy
waitlist
14
Phase I - Results
15
Who Did We Serve? – PT Reform Patient Age Distribution
Phase I - Results, cont’d
16
Who Did We Serve? PT Reform Profile (Existing CECCAC Patients) – Client Care Model Distribution
Phase I - What We Spent – Physiotherapy Reform
• Weekly spend peaked w/o September 16 ’13 – at $137,679 – Total 3972 Patients
17
Phase II - SPO Engagement • Utilizing data from Phase I
– What is the future going to look like – Service Levels
• Agreement by all SPO to utilize standardize assessment tools – Functional Assessment Matrix was
developed • 3 restorative streams based on functional
abilities assessments
18
Phase II - Community Based Assessment Measures
• Gait – Timed Up and Go (TUG) – 50 Ft Walking Test – Dynamic Gait
• Pain – Visual Analog Scale (VAS)
• Strength – Manual Muscle Testing
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Phase II - Community Based Assessment Measures cont’d
• Balance – Functional Reach – BERG – Tinetti
• Other – Elderly Mobility Scale (EMS) – Disabilities of the Arm, Shoulder and Hand
(DASH) – Barthel – Physical Performance Test (PPT)
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Phase II - Initial Restorative Streams
• Stream A – Up to 12 Weeks – 3 PT/9PTA visits
• CHRIS Stream 2 • Stream B – up to 24 weeks
– 7 PT/17 PTA • CHRIS Stream 3A/B
• Stream C – up to 32 weeks – 10 PT/25 PTA
• CHRIS Stream 3A/B 21
Phase II - Functional Indicators (FI) Chart
22
Phase II - What We Spent - Transition
• Weekly spend peaked w/o December 16 ’13 – at $18K – Total 420 Patients (298 Maintain, 122 Restore)
23
Phase II - Lessons Learned
• Most patients did not require the full 32 weeks of service to meet their goals
• Physiotherapists were not utilizing all of the assessment tools
• Outcomes collected in existing Care Coordinator assessment tools need to be aligned with the new physiotherapy model
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Phase II – Refining the Model • Reduced the number of measurement
tools used from 12 to 8 – TUG, Dynamic Gait – VAS – Berg, Tinetti – MMT – EMS, DASH
• Aligned the streams with the Provincial restorative streams
25
Phase III - Updated FI Chart Gait Pain Balance Strength Other
Self Management Goal (Patient’s own goal)
Tool Options
• TUG • Dynamic Gait
• VAS (Visual Analog Scale)
• Berg • Tinetti/Gait
• MMT (Manual Muscle Testing)
• Elderly Mobility Scale • DASH (Disabilities of
the Arm, Shoulder and Hand)
PT Stream 2 Restore to Optimal Up to 16 weeks (1 assessment + 6PT/12PTA)
TUG: 20-29 ____ Dynamic Gait: 14-16 ____
VAS: 1-5 ____
Berg: 29-56 ____ Tinetti/Gait: greater than or equal to 22+ ____
MMT: 3-5 ____
Elderly Mobility Scale: 12+ ____ DASH: 20-49 ____
PT Stream 3 A) Maintain
PT/PTA Up to 24 weeks (1 assessment + 8PT/22PTA) A) Maintain
PT/PSW (requires PSW service already in place)
Up to 24 weeks (1 assessment + 8PT/17PTA)
TUG: 30+ ____ Dynamic Gait: 13 or lower ____
VAS: 6-10 ____
Berg: 28 or lower ____ Tinetti/Gait: 21 or less ____
MMT: 1-2 ____
Elderly Mobility Scale: Under 11 or less ____ DASH: 50+ _____
26
Phase III – Refining the Model
27
Process For Admitting New Patients
Phase III - Restorative Physiotherapy Eligibility - RAI HC
28
Phase III - What We Spent – Physiotherapy Streams
• Includes All PT streams • Weekly spend peaked w/o March 03 ’14
– At $44,326 29
Phase III - Total Spend
30
Phase III – Lessons Learned • CECCAC evaluated the sustainability of the
Phase III Model • Significant financial pressure to meet the
2014-15 target of 6664 additional patients within our budget
• PT/PTA is a viable model for community based therapy service
• The change from “acute” to “restorative model” of care is a lengthy process for care coordinators and service providers alike
31
Phase III (IV) • In collaboration with our SPO we are refining
our eligibility criteria • Stream 2 eligibility
– Post acute physiotherapy – Stroke, risk for falls – 2 Physiotherapists and 6 PTA visits
• Stream 3B – 2 Physiotherapist visits to assess for PSW
supported activation/maintenance
32
Personal Support Services (PSS) Organization Engagement –
Stream 3B • Invited our PSS organizations to assist with
the development of the activation program • Physiotherapy agencies agreed to develop a
standing and sitting activation program appropriate for Personal Support Worker (PSW) supervision
• Transfer vs delegation of care to PSW
33
Next Steps
• Finalize the standing and sitting activation program
• Re-educate Care Coordinators and SPO in the new program
• Set up train the trainer modules for sustainability
34
Questions
35
Implementing the New Physiotherapy Model: Successes, Challenges & Key
Learnings
Carey Lucki Mississauga Halton CCAC
36
Mississauga Halton CCAC • Ontario’s 4th largest CCAC • Serve more than 41,000 patients annually
(2012/2013 data) • 2nd fastest growing population of seniors in
Canada (projected 32.2% increase in seniors aged 75-84; 71% increase in seniors aged 85+)
• Highly diverse area (43.2% cultural diversity)
• One of Canada’s fastest growing populations (15% by 2014)
37
Mississauga Halton CCAC
Mississauga Halton CCAC Serve the municipalities of
south Etobicoke, Halton Hills, Mississauga, Oakville and Milton.
Over 1.1 million people in the region.
We cover ~ 900 square kilometers with a mix of urban/rural composition.
38
Mississauga Halton CCAC
Strategic Plan
Mississauga Halton CCAC
Quality Community Care Outcomes Focused Patient Care
Implementing and sustaining the necessary
infrastructure, processes, care models and practices to ensure the delivery of safe, effective, evidence-based
and high-quality care to every patient, every day.
Rehabilitation Programming
MH CCAC Rehabilitation Initiatives
Mississauga Halton CCAC
Physiotherapy Model of Care (POC) November 2013
Home Independence Program December 2013
Rapid Recovery January 2014
Hips/Knees OBPs/Regional Work February 2014
Stroke Program April 2014
PT Reform Transition of
5400 patients August 2013
Phase 1 Launch of PT
Model Mid November
2013
Phase 2 Launch of PT
Model April 2013
? Query Phase 3 Fall 2014
41
Org wide All streams All SPOs
(4+ months) Data collection/Metrics
Focus Groups – Care Coordinators/SPOs Other POC sites, external stakeholders
Mississauga Halton CCAC
PT Journey
Physiotherapy New Streams of Care
Mississauga Halton CCAC 42
Stream 1 Improve and Rehabilitate to
Independent Function
Stream 2 Assess and Restore Optimal
Function (slower stream rehab)
Stream 3 A/B Maintain and Prevent Decline in
Function
Org wide All streams All SPOs
43
Mississauga Halton CCAC
Phase 1
Revised January 20th, 2014 MH CCAC
↓ ↓
↓ or ↓
0 – 90 days LOS (3 months) Up to 12 PT visits
It is expected that PT goals are met in Stream 1. If client is slow and/or not progressing
towards goal achievement, consider moving to Stream 3
0 – 60 Days LOS (2 months) PT and PTA visits
*PTA cannot be entered in CHRIS; enter all visits as PT in CHRIS
0-14 days (2 – 3 PT visits)
CSR completed by SPO
-Assessment (goals, teaching,
self-management) -Expected LOS
-Identification of other service
needs
15 – 60 days (3 – 6 PT visits)
D/C or progress
to Interval 3
61 – 90 days (2 - 3 PT visits)
D/C or consider
Stream 3
0-60 days
3-4 PT visits as required to monitor progress *CC has
discretion to add more PT if necessary*
1 - 3 PTA visits per week D/C or consider Stream 3 if
necessary
9 – 10 month LOS
PT and PTA visits or
PT and PSW (training to supervisor)
*PTA cannot be entered in CHRIS; enter all visits as PT in CHRIS
Up to 3-4 PT visits as required to train PTA and
monitor progress *CC has discretion to add
more PT if necessary*
1-2 PTA visits per week
Up to 3-4 PT visits as required to train and monitor progress
*CC has discretion to add more PT if necessary*
Add PSW time as follows: For cluster care sites, add additional units 15 or 30 mins (Enter as 1.25 or 1.50 in CHRIS)
For in home - Care coordinator has discretion to allow 30 mins -1 hour extra PSW per week to accommodate PT programme. Alternatively, it can be built into existing PSW allotment.
Tip: PTA or PSW?
PTA: Focused intervention. May involve specific stretching, more complicated exercises, some modalities (i.e., accutens)
PSW: Exercises are maintenance in nature, easily incorporated into the care plan. Gentle movement, ROM or walking small distances.
Comparison Physiotherapy Previous Model New Model Length of Stay 3-4 weeks 12 - 40 weeks Visits 2 or 3 visits 8 – 24+ visits Service Plan Assessment
Consultation Assessment Treatment Consultation
Use of other services
PT PT/PSW
PT/PTA PT/PSW
Discharge Disposition
Goals met Goals met
Type of Service Generic Specific to population/need
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Mississauga Halton CCAC
Key Assumptions Patients would begin at Stream 1 and progress through subsequent
streams if required Physiotherapists would determine total number of visits required
and length of stay Physiotherapists would identify the need for PTA involvement and
provide oversight and direction as to PTA service Physiotherapists would continue to work with PSW as in traditional
models; PSWs could now begin exercise programming as part of their care plans
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Mississauga Halton CCAC
Metrics November 2013 – March 2014
Units per patient Stream 1 3.5 – 3.9 Stream 2 4.8 Stream 3A 7.5 Stream 3B 2.9 Average 4.0
Length of stay Stream 1 30.25 days Stream 2 31.25 days Stream 3A 26.25 days Stream 3B 37 days Average 31.19 days
Stream distribution Stream 1 53% Stream 2 30% Stream 3A 12% Stream 3B 5%
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Mississauga Halton CCAC
Metrics
2012 - 2013 2013-2014 # of patients 5,082 7,537 Cost per patient $455.96
$392.62
Units 21,139 30,320 Units per patient 4.2 4.0 Length of stay
30 days 31.19 days
47
Mississauga Halton CCAC
Findings Beginning all patients in Stream 1 did not always correlate with
patient need and ‘right care’ PT utilization did not change significantly (remained at 4 units per
patient on average) Transition from 2-3 visit consultation model to a broader, expanded
role of PT which focuses on establishing SMART goals and the provision of treatment over a longer period of time
PSW incorporation of exercise programming PSW allocation Prescriptive PT/PTA visits did not always correlate with patient need
and ‘right care’ PT/PTA ‘new’ relationships
48
Mississauga Halton CCAC
November – February 2014
49
100
0
83
17
41
59
PT PTA PT PTA PT PTA
PT1 PT2 PT3A
PT/PTA Breakdown
Mississauga Halton CCAC
Challenges • Competing demands (Accreditation, DMS, other rehab programs) • Unforeseen events (Red Cross Strike) • Holidays • Hospital surges • Referral Coding
50
Mississauga Halton CCAC
Successes The benefits to our patients with these PT Streams is immeasurable if
it allows patients to be more active and safer in their home and community, and for some it allows them to stay in their home rather than have to contemplate a move to a RH or LTCF.
I like the structure of each stream, goal expectations are known, it is
not restrictive in length, clients could start in Stream 1 and progress through to Stream 2 or 3 if as per PT professional judgment/discussion with CCAC that, ongoing therapy would benefit patient. I also like that the frequency authorization is standard for all Access ordering the service, because it equalizes services for all, rather than I think they should receive 2 visits and some other Access CCs think 1 visit is enough.
51
Mississauga Halton CCAC
Phase 2 - Changes Model/framework remained the same Reinforced use of the RAI-CA rehab algorithm at intake CC chooses stream; subject to change based on initial clinical PT
assessment Visit frequency/length of stay was modified Removed the prescriptive PT/PTA visit specifications Revised the PT/PSW service plan Revised the PSR/CSR Reinforced the use of SMART goals Implemented the reporting of clinical outcome measures – pre/post
test scores
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Mississauga Halton CCAC
53
MH CCAC Physiotherapy Streams Guideline
Description Stream 1 Rehabilitate to Independence
Stream 2 Restore to
Optimal
Stream 3A Maintain & Prevent
Decline
Stream 3B Maintain & Prevent
Decline CHRIS Referral Code PT1 Rehab to Independence PT2 Restore to Optimal PT3A Maintain PT/PTA PT3B Maintain PT/PSW
Clinical Presentation
Patients who have a specific, focused need and predictable treatment/rehabilitation
journey
Patients who may have a specific, focused need and
predictable treatment/rehabilitation
journey but will take longer to meet goals (slower stream
rehab)
Patients who present with acute or chronic gait deficit, balance
deficit, reduced functional strength resulting in functional
decline in ability to perform ADLs
Patients who present with acute or chronic gait deficit, balance
deficit, reduced functional strength resulting in functional
decline in ability to perform ADLs
Eligibility Criteria Specific, focused assessment and treatment in the following areas:
• Orthopaedic (fractures) • Neurological (MS, Parkinson’s) • Respiratory (COPD) • Musculoskeletal/Exercise (post-
surgery, post injury/fall) EXCLUSION:
• OBP hips/knees • Stroke program • Rapid Recovery
• Generally – slower stream rehabilitation
• Frail, older adults • Functional loss is
reversible (capacity to improve)
• 2 or more co-morbidities with complicating factors
• 2 or more falls in last 6 months
• Decline in ability to independently perform 1 or more ADLs in last 6 months
• Deconditioning (as a result of hospital stay or exacerbation of a chronic condition)
• Need to prevent further decline
PTA criteria: -patient is expected to have ongoing changes but condition is stable and pain is controlled -PT is delegating program to PTA and continuing to supervise the PTA -evidence based program is recommended and expected to be stable over a period of time (3 wks)
• 2 or more co-morbidities with complicating factors
• 2 or more falls in last 6 months
• Decline in ability to independently perform 1 or more ADLs in last 6 months
• Deconditioning (as a result of hospital stay or exacerbation of a chronic condition)
• Need to prevent further decline
PSW criteria: -patient is stable, not changing, long term mtce -PSW may be doing a walking program -recommendations from PT are not required on an ongoing basis -PT transfers skill to PS Supervisor/PSW -PT will discharge once skills are transferred
Mississauga Halton CCAC
ACCESS – At A Glance
54
CC determines eligibility for CCAC physiotherapy service
RAI-CA is completed. Rehab algorithm is calculated (see below, next page)
Rehab algorithm score is 1-2 Patient can safely attend an outpatient
class or program without hardship
RAI – CA rehab algorithm score is 3+ Determine PT Stream based on algorithm and clinical judgement. Assign
referral to SPO. Add referral code in CHRIS
Refer to outpatient PT, falls prevention, exercise classes,
clinics
*if classes cannot accommodate patient due to wait listing, place
on Stream 1
YES
NO
Stream 1
Referral Code: PT1 Rehab to Independence
RAI-CA rehab algorithm = 3 SRC = 92 Service Plan: Block of 8 PT visits
LOS: 8 weeks
PT will likely discharge after 8 weeks
Stream 2
Referral Code: PT2 Restore to Optimal
RAI-CA rehab algorithm = 4 SRC = 93 Service Plan: Block of 12 PT visits (combination of PT/PTA - PT will determine
how much PTA) LOS: 8 weeks
PT will need to revise PED after 8 weeks with community CC.
Stream 3A
Referral Code: PT3A Maintain & Prevent
RAI-CA rehab algorithm = 4/5 SRC = 93/94 Service Plan: Block of 12 PT visits (combination of PT/PTA – PT will determine how much PTA)
LOS: 8 weeks
PT will need to revise PED after 8 weeks with community CC.
Stream 3B
Referral Code: PT3B Maintain & Prevent
RAI-CA rehab algorithm = 4/5 SRC = 93/94 Service Plan: Block of 4 PT visits (combination of PT/PSW) PT will determine if PSW can be used for exercise programming and communicate with Community CC. LOS: 8 weeks. PT will need to revise PED after 8 weeks with community CC and/or discharge.
Mississauga Halton CCAC
Successes • Bi weekly meetings with 4 contracted rehab SPO agencies “Best Practice Rehabilitation Committee” • Frontline CC roadshows and team meetings • Identified Care Coordinator ‘rehab’ champions per team • THP/HHS/CVH road shows – allied health and patient
navigators/discharge planners • Formed a outcome based metrics committee to further inform:
% patients per stream Cost/utilization Clinical outcome measures Patient satisfaction Discharge disposition – referral to exercise classes/falls
prevention classes, CSS • Intranet
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Mississauga Halton CCAC
PT Models of Care
56
Where are we? • Phase 2 launch – April 2014 • Change management curve is moving upwards with acceptance,
experimentation, and integration • Costs are on the rise ~ 21% more per month • Stream breakdown:
Stream 1 30% Stream 2 46% Stream 3A 10% Stream 3B 14%
• Clinical outcome measures - too early to analyze • Metrics analysis • PSW engagement
57
Mississauga Halton CCAC
Questions
Mississauga Halton CCAC 58
Central West CCAC
Physiotherapy and Exercise and Falls Prevention Program
Kimberley Floyd
Central West CCAC
June 9, 2014
Overall Vision:
To Develop a Sustainable Physiotherapy / Exercise and Falls Prevention Program
in the Central West Region
Execution of PT Reform in Central
West LHIN • Allowing for continuity of care between in-home physiotherapy
and exercise and falls prevention with CCAC implementing and overseeing both streams
• Developing a flexible, streamlined and innovative delivery model that blends exercise and falls prevention classes to optimize available resources and maximize outreach to seniors
Physiotherapy Continuum
• Consistent service provider treats patient within neighbourhood
approach to care (congregate setting and in home/community settings)
• Patient progresses through streams that meet their presenting needs within safe and effective transition between streams with no gaps in service or redundancy in assessments and treatment
• Execution of recommended PT streams across all service providers supported by exercise and falls prevention classes as an extension of any one on one in home stream
• Care offered across continuum close to home in neighbourhood locations across the LHIN
Exercise and Falls Prevention Classes
• Implementing a combined Exercise and Falls Prevention education service delivery model
• Ensuring continuity of care
• Optimizing available resources and maximizing outreach to seniors through innovative model of care
• All classes are replicated in congregate and community settings including specialized classes sensitive to community needs (mental health, culture and disease specific)
Exercise and Falls Prevention Model
• Each class has a blended approach of exercise and falls prevention built into every class
• Classes run 48 weeks a year • Overseen by regulated health care professional • PTA runs the class under a supervision model by the PT • Congregate settings and Community Based classes are supported
by this model • Building of strong community partnerships for community sites
including Recreation and Parks departments, municipalities, primary care practices and other community settings
• Self management and chronic disease management education components built in through interprofessional team based organized sessions
Commitments of PT Model
• Committed presence of therapy team in congregate settings to integrate into the inter-professional team
• Consistent team of therapists working within each congregate setting
• Provide a continuum of care with in home Physiotherapy and exercise and falls prevention classes with PT and PTA model
• Communication/documentation within congregate settings • Support in falls prevention programs in Retirement Homes as per
Retirement Home Act • Timeliness of interventions (reduce waste in the process or
unnecessary bureaucratic steps) • Main elements of model replicated across all locations • Model transferable to in home focus
Lessons Learned
• Communication: Process is required for weekly established meetings between PT care team and
Retirement Home PT and PTA of class and in home therapy must be supported to case conference
• Oversight:
Supervision Model is imperative between PT and PTA PT needs to have professional accountability for whole model Appropriate compensation must be offered to support program oversight,
supervision, care planning and participation in falls prevention programming Standardizing quality metrics across continuum that is evidenced based
• Intake Process:
Needs to be seamless and real time Encourage therapist and congregate setting to forward a referral and then
receive immediate authorization to assess patient (supports transition from hospital to home as one example)
Logistics • Screening Processes to recommend class best suited to the needs
of the senior and to support service outcomes by regulated health care professional
• Seniors registered in desired classes (location and time convenience) in order to maximize consistent attendance in classes
• Attendance monitored for all class settings (congregate and community locations in order to provide CSS sector statistics)
• Care Coordinators attached to congregate and community sites as points of contact and patient level care planning and system navigation
• Strengthened collaborative care planning that extends beyond PT reform (proactive service planning opportunities)
Five Pillars of Ideal Continuum of Care
Continuity of Care Team
(PT, PTA and Care Coordinator)
Proactive Communication Approaches in
Congregate Settings
PT and PTA Integrated into Care Team in Congregate
Setting
Documentation Practices that
Support Interprofessional Care Planning
Seamless and Timely Access to
Service
Retirement Home Partnership
• Collaborative service planning around falls prevention which includes monitoring and reporting of falls
• Informing program design
• Commitment of regular engagement re refinement of model
• Established planning days to ensure development of quality outcomes
• Satisfaction of model is continually explored based on the above practices
• CCAC Managers aligned with all congregate settings in order to escalate any issues in real time
Benefits
• Seniors are navigated to appropriate health services by leveraging existing system structure of CCAC
• Utilize centralized function to implementation and navigation that ensures efficiencies and better quality in providing services and monitoring of service providers
• One stop source of information for program options for seniors and other stakeholders
• Reduced delay in access to services
Benefits Continued
• Individualized plan of care for seniors involved in services from a care team who is proactively meeting their needs
• Preventative approach to educating on the multi factoral elements of falls prevention by leveraging use of interprofessional resources in neighbourhoods
• Evaluation and outcome measurement is strengthened as a critical mass of locations exist with a consistent approach to the model of care
• Sharing of best practices to create a Community of Practice among providers in Central West LHIN
Questions
Kimberley Floyd Director of Client Services, Central West CCAC
905-796-0040 ext. 7705 [email protected]
For More Information Laszlo Cifra
Program Director, Integrated Care, CE CCAC 416 750 2444 x 5558
Michelle Nurse Director, Contracts and Relationships, CE CCAC
905 430 3308 x 5247 [email protected]
Carey Lucki Program Manager, Patient Care, MH CCAC
905-403-5354 [email protected]
Kimberley Floyd Director of Client Services, Central West CCAC
905-796-0040 ext. 7705 [email protected]