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Implementation of a Care Stream Model Supporting an Integrated Regional Rehabilitation System Across the Continuum of Care
June 2, 2017
Presented by: Susan Franchi, St. Joseph’s Care Group Denise Taylor, St. Joseph’s Care Group
Presentation prepared by: Kathleen Lynch, Vice President Rehabilitative Care and Chronic Disease Management Janine Black, Director Inpatient Complex Care and Rehabilitative Care Susan Franchi, Director (Presenter) Outpatient Rehabilitative Care and Chronic Disease Management Denise Taylor, Coordinator (Presenter) Rehabilitation Review St. Joseph’s Care Group John Clack, Manager Medically Complex Services
Supported by:
About Us
St. Joseph’s Care Group is a Catholic organization
that identifies and responds to the unmet needs of
the people of Northwestern Ontario
Core Service areas include: Addictions & Mental
Health, Rehabilitative Care & Chronic Disease
Management and Seniors’ Health
Programs and services are provided throughout
the community and at nine different sites
Our Care Stream Vision
An integrated rehabilitation system across the full continuum of care:
Inpatient/outpatient community where individuals receive client-centred culturally- safe care from an interprofessional team as close to home as possible
4
8
CCC
20 8
7
7
13 12
174
Rehabilitation
50
4
9
Convalescent Care
10
Current State
Creation of a Care Stream Model
Client referrals to St. Joseph’s Care Group Programs and Service are accepted from all levels of care
Thunder Bay Regional Health Sciences Centre
Regional Healthcare Facility
Community or Primary Care
Care Stream Model Supports:
Evidence-based care (Practice level)
QBP adherence (Practice level)
Standardization (System level)
Improved access and transitions (Practice level)
Effective use of resources (Organizational level)
Clinical Lead Physician Specialist
Inter-professional Team For Triage
Assessment Treatment
Regional Providers
Regional Providers
Regional Providers
QUALITY CARE COLLABORATION EDUCATION
INPATIENT OUTPATIENT COMMUNITY
Outpatient Role
Designed to:
Prevent clients from entering the hospital system
Ensure clients have access to appropriate outpatient services so they can return home
Examples
Frail Seniors’ Pathway from the ED with Rapid Response to interprofessional geriatric assessment
Inpatient to outpatient neurology services
– smooth transfer
– telemedicine speech-language pathology
The Care Stream Model:
Provides the right care, at the right time, in the right place
– As close to home as possible
Provides access to rehabilitation which optimizes function
Organizes the continuum throughout the region
The Care Stream Model:
Provides opportunities to work with regional partners
Standardizes definitions and performance metrics
Streamlines referrals
Findings
Need for a regional network for clinician communication, education, and skill development
Need for capacity building throughout our region including physician specialists (rheumatology, geriatric psychiatry, physiatry)
Summary
Next Steps: Implementation and Evaluation
Preventative Opportunities
Reactive
