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Smoother Transitions Better Outcomes Building a Framework to Rethink Rehab

Provided to the Central West Local Health Integration Network Final Report August 2010

Smoother Transitions, Better Outcomes – Building a Framework to Rethink Rehab in the Central West LHIN 2 Corpus Sanchez International Consultancy

Table of Contents 1.0 Our Starting Point: How We Got Here ......................................................................................... 4

Setting the Context ........................................................................................................................... 4 Moving Forward – Charting a New Course ....................................................................................... 4

2.0 Confirming the Burning Platform .................................................................................................. 5

Confirming Consensus for Change ................................................................................................... 5 Reviewing Where We Are and Where We Want to Be ..................................................................... 6

3.0 Charting a Path for the Rehabilitation Journey ........................................................................... 7

Establishing a Vision for Rehabilitation ............................................................................................. 7 Designing a New Community of Rehabilitation ................................................................................. 9

4.0 Defining Priorities for Action ....................................................................................................... 10

Framework for Recommendations .................................................................................................. 10 Quality Dimension #1: Truly Patient and Family Centred Care ...................................................... 11 Quality Dimension #2: Enabling Appropriate Access ...................................................................... 12 Quality Dimension #3: Safe, Effective, Efficient .............................................................................. 13 Enablers for Transforming Rehabilitation ....................................................................................... 14 Building a Roadmap to Move from Plan to Action .......................................................................... 15 Challenges in Building a Roadmap and Implementation Plan ........................................................ 18

Appendix ..................................................................................................................................................... 19

Appendix A: Stakeholders Consulted ............................................................................................ 19 Appendix B: Community Partner Grouping – Examples of Organizations and Institutions ............ 21 Appendix C: Lessons from Abroad ................................................................................................ 22


“Rehabilitation is one sector of the healthcare system in which resource allocation has not been proportional to the need for service, and where resource levels have been significantly reduced”

The Rehabilitation Reform Initiative March 2000

Rehab Affects Us All The concept of rehabilitation in its broadest sense is a process that affects virtually everyone’s life on a daily basis. From the simplest acts like deciding to join a gym and increase general fitness, to teaching ourselves the lifestyle changes necessary to reduce coronary risk factors, to learning to cope with a formally diagnosed chronic health situation such as diabetes, to being sick or having some injury where we need time and a plan for recovery, rehab helps us to maximize our personal function.

Given the breadth of depth of what rehab is and how rehab affects, one of the biggest challenges for coming up with a plan for rehab is how to define what “it” is so that people can have it fit within their individual or collective archetypes. These patterns of thought are generally driven from a provider-centric, historical bias that is grounded in a need to neatly fit things into boxes thereby creating silos – this is health care today. To have true impact, rehab must be focused on the patient’s journey to maintain and restore their abilities.

Changing this reality will be a major challenge. However, there is no other option.


1.0 Our Starting Point: How We Got Here Setting the Context The story of rehabilitation services in Ontario has had a very similar beginning – one focused on responding to the needs for transitions out of acute care, following an illness or injury. This beginning should not be viewed as good or bad, but rather a reality of history. Over the past 10 years, a transformation agenda has emerged that acknowledges a need for better integration of services and a more systemic approach to care delivery that extends beyond acute care. This emerging agenda recognizes that self care, primary health care and prevention programs, community-based and home-based services, acute care, complex continuing care and rehabilitation services must work together collectively to keep people healthy, help them get better when they are ill, and help those who must live with their illness and disability. While most would not challenge this emerging agenda, many would agree that change is long overdue. The need for change is also being driven by growing demands for care for an expanding population and demographic base, heightening fiscal pressures, ongoing pressures in acute care related to ER wait times and Alternate Level of Care, and very real health human resource challenges. These challenges have underscored the urgency for finding and actualizing a new path for rehabilitation care. Maintaining a traditional mindset to care delivery will neither fix nor address these challenges or needs. There is a critical need to rethink rehabilitation services and what it means to the lives of the people who live in the Central West LHIN.

Moving Forward – Charting a New Course The fundamental rethink of rehabilitation has become a top priority of the Central West LHIN to ensure timely, appropriate and effective transitions of care, all focused on one overarching goal – patient family centred care that meet the needs of the people served. In its second Integrated Health Services Plan (IHSP), the Central West LHIN recognized rehabilitation services as a critical enabler to meet the increasingly complex needs of patients, to assist in relieving resource pressures within acute care, to strengthen capacity of other services where increased demand is expected, and to enhance the development of specialized services and expertise to support providers along the broader continuum of care. As a result, rehabilitation was flagged as one of seven programmatic areas under the strategy of creating comprehensive, integrated LHIN-wide programs to create a critical mass of high quality treatment and care across the continuum. To chart a new course for rehabilitation, the Central West LHIN engaged multiple stakeholders (see Appendix A) from across the continuum to establish practical, measurable initiatives that will lead to a strategic framework through which rehabilitation priorities will be achieved. Through a series of interviews, expert panels, and a planning forum, 49 rehabilitation leaders and stakeholder provided valuable input into reframing rehabilitation. The result - a new vision for rehabilitation, a clear set of recommendations, and a roadmap to move from plan to action has been developed to build a stronger, more responsive rehabilitation system that will support an individual on their journey to maintain and restore abilities. This work builds on and leverages a great deal of planning that has been done in the past, either within the LHIN, through regional or provincial planning processes, or by leveraging experiences and research from other jurisdictions. It also builds on the core strengths of the multiple providers and is intended to harness their individual and collective experiences and energy to make rehabilitation better. But the LHIN was very clear when it launched this process. Plans have been written in the past and have stalled when it comes to implementation. This process must, and will, be different. This is not about planning. This is not about creating an exhaustive inventory of the system as it has been and as it is. This is about developing an action-oriented strategy to make rehabilitation better. In the pages that follow, consensus for change is confirmed, a collective vision and framework for how rehab can work together is described, and a roadmap to move from plan to action is presented.


2.0 Confirming the Burning Platform Confirming Consensus for Change Great care is delivered everyday both within and outside the Central West LHIN all focused on meeting people’s needs for some form of rehabilitation. However, in the absence of a comprehensive vision and plan to guide and align the growth of rehabilitation service delivery, programs and services have been developed largely within silos. For example, focus has typically been along provider and facility lenses, with a growing focus towards patient-focused and advisory group lenses. While each group aims to deliver optimal care, their collective delivery of services can still be sub-optimal if they are not coordinated resulting in barriers for clients and families to navigate across the continuum. The following diagram depicts the mis-alignment that may occur as we move from understanding needs to delivering on needs. In physics, this is referred to as refraction – changing the direction as we pass from one medium to another.

This silo approach will not effectively address the 8% rise in rehab beds staffed, 16% increase in rehab bed days, 18% increase in rehabilitation separations, or the 1 out of every 4 acute ALC discharges waiting for rehabilitation. Nor is it structured to meet a population that has a significant elder population. A new way of framing the solution is required. The intent of this report is not to spend a great deal of time describing the current state of rehabilitation services. Simply put, the past and current state is viewed as our starting point. This report acknowledges that a significant volume of work has been completed to date within sectors, and this work must be integrated into a solution. This report is about change and about strengthening rehabilitation by building an overarching framework for rehab that ensures needs are understood and addressed across the broader patient journey. On that point, the participants in the various stages of this process were asked if change is needed.

Having agreed that change is needed, the Central West LHIN and its multiple partners needed to confirm what change might look like, how it will be different from today and why it will be better.


Reviewing Where We Are and Where We Want to Be Rehabilitation is a critical component of the continuum of care. While rehab can reduce length of stay in acute care hospitals, decrease readmissions, and decrease visits to doctor’s offices and emergency rooms – this is not the true potential. Rehab can help prevent and postpone disabilities from occurring – this is real impact. The following table summarizes stories from stakeholders describing where we are today, and where we want to be.

Where are We Today? Where do We Want To Be?

Focu

s on

Patie

nt &

Fam

ily C

entre

d Services not patient, but provider-centered Lack of support for family caregivers’ needs Care delivery is institutionally focused

resulting in a system that is viewed as a series of silos – not connected, not coordinated, not networked

Lack of early assessment to have proper responses in place when needed

To be truly patient and family centric – driven by a quest to ensure that patient needs are met and that they are appropriately involved in care decisions

Invest in building a “trusting” environment, with strong communication between patients & families and providers

Creating a network focused on the patient Focus on healthy living and wellness

Focu

s on

Safe

ty, A

cces

s and

Flo

w

Variation in capacity and practices exist. Major differences in system response to the four “big” rehab conditions yet demographics, course of disease, pathways are predictable

Care delivery is focused around a single professional focus under an episodic care model, not centred on interprofessional care using a continuum model

Gaps in knowledge of what is available from all facilities/agencies – insular mindset focusing on ones “own walls”

Access to rehab is determined by where you live and who pays for your service

Barriers to access include inability to pay for services that are only private sector

Challenges for directing patients to the right service, in the right location, at the right time

Reduce unnecessary variation in practices (e.g., Length of Stay) and processes (e.g., policies and procedures like admission criteria) through integrated practice, interprofessional models, and agreed upon pathways that extend across continuum

Support for care close to home Enhanced focus on navigation, both within

sectors and across the continuum Exceptional handoff processes that

eliminate process breakdowns Plan discharges and transitions across the

continuum from Day 1 using a 7 day a week mindset

Integrated strategies surrounding key safety initiatives (e.g. falls prevention)

Focu

s on

Effic

iency

and

Effe

ctive

ness

Lack of timely planned care including less than ideal education that impacts service effectiveness and potentially outcomes

Limited understanding of access points resulting in multiple referrals

Lack of consistent standardized performance measures used across the continuum of care

Lack of accurate and complete data making it difficult to monitor access/identify problems

Enhanced opportunities for reentry or entry into rehab to ensure services are accessed in the right place at the right time. Rehab must not be a destination

Ensure resources across the broader continuum are aligned and coordinated to meet the needs of the patients

Produce periodic performance reports on access and utilization to show variability and gaps (outcomes, costs)


3.0 Charting a Path for the Rehabilitation Journey

Establishing a Vision for Rehabilitation The Central West LHIN’s vision for creating “a local health system that helps people stay healthy, delivers good care when they need it, and will be there for their children and grandchildren” will be enabled by a vision for

Creating a Rehabilitation Community that supports patients through their journey to thrive, restore, and maintain life to their fullest abilities

We will know we have met this vision when we:

- Deliver the care that we want for ourselves to each resident of the LHIN. We will strive to sustain the highest level of patient, family, and provider experience regardless of where they receive their care.

- Establish sustainable partnerships amongst providers across the continuum to ensure timely access to appropriate care and services. We will nurture relationships amongst our integrated group of provider partners to ensure residents get the care they need, at the right time, delivered by the right provider using a systematic approach to care underpinned by evidence .

- Improve the quality of life for residents of the LHIN by delivering clinical care that sets the standard for excellence - safe, effective, and efficient care. We will foster a culture of quality that is focused on the safe delivery of care and services for patients, while also ensuring resources are utilized effectively and efficiently to support the ongoing sustainability of the system.

Building a Supportive Definition for Rehabilitation To meet this vision for rehab, the definition of rehabilitation must shift from being reactive in nature to support recovery from illness and injury, to be a more contemporary definition resulting in a robust rehabilitation model that stretches from the prevention to enable individuals to stay healthy, to episodic care to regain health, to living with illness or disability, and ultimately to support end of life care needs. Our definition for rehabilitation is a progressive, dynamic, goal-oriented process enabling individuals to identify and reach their optimal mental, physical, cognitive and/or social functional level through client focused partnerships with family, providers, and the community. Fortunately, there appears to be a desire that rehab must be an integral and essential component of a safe, effective and accessible healthcare system. This is driven by an understanding that virtually every member of society can expect to need rehabilitation services at some point in their lifetime.


Building a New Rehabilitation Community for the Central West LHIN


Designing a New Community of Rehabilitation A common question many will ask is – what will be different this time? Over the past fifteen years, there have been numerous studies, commissions, and expert planning groups that have examined specific elements of the rehabilitative continuum and provided targeted solutions of value. However, the solution for rehab does not rest in any one particular area or any single provider sector, but is grounded in bringing the broader continuum together in a collective, seamless framework that will enable rehabilitative stakeholders to work together to meet the needs of patients. The goal: a single standard of care for rehabilitation. For the health system to be accessible, patients must be guided through the continuum to ensure each patient receives the right care, at the right time, in the right place. The following conceptual rehabilitation framework depicts a seamless rehab care delivery model for accessing services based on their physical, cognitive, social or environmental needs, across inter-connected continuum from home-based, primary care-based, acute care and community-based services that enables multiple direct entry points enabling individuals to maintain, restore, and thrive to their fullest abilities. See Appendix B for an Example of Organizations and Institutions.

Physical

Cognitive

Social

Environmental

Thriving Restoring Maintaining

Community Social Services

Advocacy & Peer Support Organizations

Research & Education Networks

Professional Associations

Resource & Information Services/ Centres

Home Based Services

Hospital Based

Services & Clinics

Private Based Services

Primary Care & Community

Partners

Residential Facility Based

Services

Our Vision for Rehabilitation

A Rehabilitation Community that supports a patient through their journey to thrive, restore and

maintain life to their fullest abilities


4.0 Defining Priorities for Action

Framework for Recommendations To deliver on the vision for rehabilitation, priorities for action will be referenced based on three quality dimensions:

Truly patient and Family Centred Care. Rehabilitation needs to be provided using a client and family-centred approach, and must be based on consumer driven initiatives. Services must be designed around patient needs as defined by the patient, not the provider to improve their quality of life and enable participation in society.

Enabling Appropriate Access. Planning must enable equitable access to rehab services, support timely transitions across the broader continuum based on evidence and best practice, and supported by adequate service capacity.

Safe, Effective, Efficient. A renewed mode for rehabilitation care must be safe for patients and providers, meet the needs of patients and provider, and do so in a manner that efficiently utilizes available resources.

Achieving priorities for action will be grounded in core enablers.


Quality Dimension #1: Truly Patient and Family Centred Care


Quality Dimension #2: Enabling Appropriate Access


Quality Dimension #3: Safe, Effective, Efficient


Enablers for Transforming Rehabilitation


Building a Roadmap to Move from Plan to Action To transition from a plan to action, the Central West LHIN must build and support a roadmap that will ensure necessary preparations are made to support the implementation and ensure the changes have led to the expected outcome. The following 5-step roadmap has been developed as a starting point.

Step 1. Endorsing of the Report. Step 1 is a critical step to renewing the rehabilitation model within the Central West LHIN. It requires the LHIN to formally and publicly endorse the strategy and to clearly communicate the rationale and plan to partners, stakeholders and staff. Based on discussions with the LHIN to date, this action should take place within one-month of receiving the report. Note: endorsement does not mean every finding and recommendation is supported, but rather the evolving vision of the Community for Rehab is supported in principle.

Step 2. Mobilizing a Team to Lead to the Renewal The next critical step is to put the key Leadership Team in place to lead and direct the renewal, and to ensure the Team is focused in their efforts. The Team will be an influential group that is charged with overseeing all aspects of the renewal implementation – the Rehab Renewal Leadership Team. This structure is critical to ensuring the renewal plan moves forward and key barriers are managed, getting ongoing support and buy-in from key partners, assisting with developing support amongst physicians and other providers, reviewing strategic plans submitted by individual working groups and making strategic intent decisions, providing advice to support implementation of recommendations, and approving an evaluation framework to assess the success of the renewal strategy implementation. As a start, the Rehab Renewal Leadership Team will oversee the development of Project Charters for the next phases of work (e.g., charter for each initiative, or a charter for phases of work). The Charter will clarify why the project is being conducted, describe the proposed qualitative and quantitative outcomes to be achieved by implementing the strategy, describe the team and resources for supporting the implementation, identify risk issues and mitigation strategies, and provide a workplan for moving forward. Core Activities within this step include identifying champions and creating the Leadership Team to oversee planning, implementation and evaluation; confirming the vision and high level recommendations; confirming priorities, identifying the necessary supports to support moving forward (e.g., working groups, implementation teams, change management capacity), populating the working groups to lead the work. The Leadership Team will also engage institutional CEOs in open dialogue to gain top-level commitment to the efforts and support removal and management of system barriers.


The following diagram describes the proposed organization structure to support the implementation of the Rehab Care Renewal Strategy. Working groups will be defined around the defined areas for action (see Step 3).

Executive LeadTBD

Project Management

Office

Rehab Renewal Leadership Team

Working Group

B

Working Group

C

Working Group

D

Working Group

E

Working Group

A

Implementation Support Teams

Central West LHIN Board


Step 3. Develop a Focused Plan of Action To truly have impact, a focused plan must be developed that identifies where the change will start. To assist in the process, core initiatives to support the rehabilitation renewal must be identified under three timeframes: Short Term (first 90 days), Medium Term (first 6-12 months), and Longer Term (1-2 years). Based on discussions to date, the following initiatives were identified as a potential starting point:

Short Term First 90 Days

Mobilize the Leadership Team, supporting structures (e.g., Working Groups, Project Management Office), and related project management activities.

Development and implementation of a multi-prong communication strategy to inform a broad group of stakeholders (e.g., the public, institutional providers, advocacy groups, government) in the multi-year rehab transformation with clear year to year targets.

Confirm and obtain agreement on the role of Headwaters, Osler, the Central West CCAC and other community organizations (“the partners”).

Confirm admission, discharge and transfer protocols. Initial focus on Headwaters, Osler and CCAC transitions, with a plan to stretch into specialized rehab facilities and long term care facilities.

Medium Term 6-12 Months

Develop the role of “the partners” to support the evolving nature of the rehab renewal.

Establish the system-wide accountability framework for rehabilitation services. Identify, prioritize and develop standardized care pathways. Initial focus on

musculoskeletal rehab needs. Launch a population approach that reflects the LHIN’s commitment to seniors.

Longer Term 12 Months and Beyond

Confirm accountability measures/metrics and incorporate into accountability agreements.

Evaluate the role of “the partners” in supporting the renewal and achievement of goals.

Establish approaches to align incentives. Policy development. Institute patient based funding models. Support research and innovation agenda.

Step 4. Changing How We Deliver Care – Implementation Following planning efforts, implementation is expected to occur using a phased approach. To support these activities and to ensure coordination of efforts, Working Groups for core change efforts will be assembled that will function under phases of time. A Project Management Office will oversee delivery. Step 5. Performance Evaluation and Ongoing Monitoring In Step 5, the LHIN will evaluate both the success of the renewal initiative implementation as well as measure rehab care performance on an ongoing basis based on established measures.


Challenges in Building a Roadmap and Implementation Plan A number of challenges were identified that must be managed when completing implementation planning and implementation itself. Need to clearly understand: Implementation Team’s Skillsets, Capacities, and Experience. It is very important to understand

what resources will be supporting the implementation in order to appropriately assign accurate estimates.

Gaining consensus. Given the number of organizations potentially involved in any change initiative related to rehab, the challenge will be getting agreement that rehab is a priority that requires attention in a setting where rehab could be competing with other organizational priorities. LHIN Directives can be used to overcome this issue, and this may be required.

Relative Priority of Initiatives. While a number of recommendation options exist, it is critical to understand which recommendations will be pursued to appropriately prioritize recommendations. Priority of initiatives must be evaluated based on relative challenges to implement, barriers to obtain buy-in support, cost, time, strategic influence, etc.

Availability of Resources. Both the number and availability of resources will dictate how quickly a workplan can be implemented.

Senior Stakeholder Level Support. Need to clearly understand which initiative will either have or not have the “stamp of approval”.

Natural Resistor for Working Together. Need to understand the natural resistance factors for the many organizations and stakeholder to think outside of their individual areas of focus.

Organizational Fatigue. Virtually all organizations in the health care system today are struggling to balance demands and costs, and are pursuing multiple internally driven and externally oriented projects focused on sustainability. Virtually every organization the consultants encounter are now reporting a level of change fatigue that makes launching any new initiatives more difficult.

Timing – Can the LHIN Afford to Wait. This is an issue of timing. The LHIN must determine how long it can afford to wait before changes are implemented? Is there a sense of urgency?


Appendix

Appendix A: Stakeholders Consulted Peel Halton Acquired Brain Injury Service Carol Williams, Executive Director Scott Faraway, Clinical Director

West GTA Stroke Network Carmel Forrestal, Regional Stroke Coordinator Dr Andre Douen MD, Neurologist, Medical Director Regional Stroke Program

Bone and Joint Network Rhona McGlasson, Project Director

Toronto ABI Network/GTA Rehab Network Charissa Levy, Executive Director

Headwaters Health Care Centre Liz Ruegg, Vice President and Chief Nursing Officer Mary Wheelwright PT, Director, Rehabilitation Services Dr Nadine French MD, Physician responsible for HHCC CCC beds Catherine Kurz, Discharge Planner

William Osler Health System Liz Buller, Senior VP and Chief Nursing Officer Jane deLacy RN, Director for Surgery and Ambulatory Care Ingrid Fell RN, Director Seniors/CCC and General Medicine Dr Ian Smith, Chief of Staff Jane Keppy, PT, Manager of Inpatient Rehabilitation Melissa Morey-Hollis, Professional Practice Leader

Central West Community Care Access Centre Dilys Haughton, Senior Director Client Services Margaret Paan, Director Client Services Charmaine Scarlett, Community Case Manager Aline Payne, PT, Community Case Managers Karen Legister RN, Community Case Manager Sandra Fletcher RN, Case Manager Dale Miller PT, Case Manager.

Private Practitioners Debbie Jones-Snyders, Director, South Central Region, Community Rehab Heather Heaman, SLP, Heaman Communication Services Inc. Brenda Labron, President, Therapy Partners


Long Term Care Amanda Coulter, Director of Care, Faith Manor Brenda Urbanski, Administrator, Dufferin Oaks Iona (Nurse), Behavioural Support Team, Kipling Acres Bob Babak, Beharioural Support RN,Kipling Acres

St John’s Rehab Hospital Malcolm Moffat, President and CEO

West Park Health Care Centre Anne-Marie Malek, President and CEO

Toronto Rehabilitation Institute Dr. Geoff Fernie, Medical Director Mark Rochon, President and CEO

Academics Stakeholders Michel D. Landry PT, PhD Maureen Markle-Reid, RN, MScN, PhD Dr. Mark Bayley

Central West LHIN Mimi Lowi-Young David Colgan Pat Stoddart Mark Edmonds Tellis George Lana Dunlop

Others Enza Ferro, Ontario Hospital Association Priti Patel, Mississauga Halton LHIN Joe Mauti, Mississauga Halton LHIN Glen Flint, Toronto Central LHIN Corrine Kagan, Ontario Neurotrauma Foundation Tara Jeji, Ontario Neurotrauma Foundation


Appendix B: Community Partner Grouping – Examples of Organizations and Institutions

Community Partner Grouping Examples of Organizations/Institutions Primary Care Providers & Community Based Services

Physician Offices Family Health Teams Community Health Centres (e.g. Bramalea , Rexdale) Public Health Health and Care Centres Private physiotherapy and rehab centres Fitness Centres Wellness Centres Massage therapy centres and spas Faith based & volunteer services Parks and Recreation Volunteer service providers (e.g. Seniors support services)

Home Based Services CCAC programs and services Self care Family supported care Live-in caregivers

Other privately funded in-home services Community Social Services Adult day programs, Assisted living, Supportive housing Residential Facility Based Services

Long term care homes (public and private) Assisted Living environments Supportive housing

Retirement homes Hospital Based Services & Clinics

Inpatient beds/program at specialty rehab hospitals Inpatient beds/program at community hospitals Hospital-based clinics

Outreach services Private Based Services Private rehab practices and Chiropractic services

Home care support agencies Resource and Information Services and Centres

Teleheath Ontario Peer Support & Advocacy Organizations (e.g., Canadian

Paraplegic Association) Heath Promotion programs Community Based Pharmacies Diabetes Education Centres Chronic Disease Management Programs Internet resources

Public Health Units Advocacy & Peer Support Organizations

Ontario Brain Injury Association, Heart and Stroke Foundation of Ontario, Osteoporosis Canada, Canadian Diabetes Association

Research & Education Networks GTA Rehab Network, Bone & Joint Network, Ontario Stroke Strategy, Ontario Neurological Foundation

Professional Associations Ontario Hospital Association, Ontario Physiotherapy Association, Occupational Therapy Association of Ontario, Ontario Association of CCAC, College of Physicians and Surgeons of Ontario


Appendix C: Lessons from Abroad Community Based Rehab The UN describes "Community-based rehabilitation (CBR) as a strategy for enhancing the quality of life

of disabled people by improving service delivery, by providing more equitable opportunities and by promoting and protecting their human rights.

It calls for the full and co-ordinated involvement of all levels of society: community, intermediate and national.

It seeks the integration of the interventions of all relevant sectors - educational, health, legislative, social and vocational - and aims at the full representation and empowerment of disabled people.

It also aims at promoting such interventions in the general systems of society, as well as adaptations of the physical and psychological environment that will facilitate the social integration and the self-actualization of disabled people.

Its goal is to bring about a change; to develop a system capable of reaching all disabled people in need and to educate and involve governments and the public.

CBR should be sustained in each country by using a level of resources that is realistic and maintainable. At the community level, CBR is seen as a component of an integrated community development programme.

It should be based on decisions taken by its members. It will rely as much as possible on the mobilization of local resources. The family of the disabled person is the most important resource. Its skills and knowledge should be promoted by adequate training and supervision, using a technology closely related to local experience.

At the intermediate level, a network of professional support services should be provided by the government. Its personnel should be involved in the training and technical supervision of community personnel, should provide services and managerial support, and should liaise with referral services.

A fully integrated CBR system should seek to draw on the resources available both in the governmental and non-governmental sectors.

At the national level, CBR seeks the involvement of the government in the leading managerial role. This concerns planning, implementing, co-ordinating, and evaluating the CBR system. This should be done in co-operation with the communities, the intermediate level and the non-governmental sector, including organisations of disabled people."

Australia Commitment within the formal health system for increased emphasis on rehab in the home

environment. Cochrane Collaborative attempted in 2003 to assess adequacy of home- or community-based services

but struggled with limitations re: data. Growing emphasis on serving the aged more effectively. Introduced Community Partners Program to manage care more effectively for people with linguistic or

cultural barriers that affect access. The core objective of the Community Partners Program (CPP) is: Promoting and facilitating increased and sustained access by culturally and linguistically diverse communities with significant aged care needs to aged care information and services.


The NHS A recognition in 2009 that patients have uncertain futures after hospitalization that includes a critical

care component. Discharge from critical care is viewed as the start of an uncertain journey to recovery characterised by,

among other problems, weakness, loss of energy and physical difficulties, anxiety, depression, post-traumatic stress (PTS) phenomena and, for some, a loss of mental faculty (termed cognitive function).

Family members become informal caregivers, and this itself can exert a secondary toll of ill-health; family relationships can become altered and financial security imperilled. Recovery from illness is highly individual.

Led to creation of NICE guidelines to address rehab needs following an illness with critical care as part of the inpatient stay

Raising the Bar initiative launched in 2007 to raise the profile and improve the provision of rehabilitation services for cancer and palliative care patients

Led to an 18-month focus to undertake an evidence review and develop an evidence base for therapy interventions;

Result was tumour specific therapy intervention pathways and an emphasis on re-modelling service provision

Future focus is continuing on a range of national projects and the showcasing of new models of care United States - The “75% World” IRFs must have 75 percent of patients fall into 13 strictly defined medical conditions Largely biased towards acute trauma and neurological patients and against orthopedic patients If compliant, IRFs are considered exempt from the acute care inpatient hospital PPS Compliant IRFs

are paid under separate IRF-PPS; if non-compliant, IRFs receive lower reimbursement under traditional acute IPPS (under DRG system)

In addition to meeting or exceeding the “compliance threshold,” IRFs must meet other, additional classification requirements (i.e. staffing, facilities, level of care)

Penalties for compliance failure are almost certainly financially catastrophic In the 75% world, successful IRFs are using many strategies: Internal Strategies

- Collaboration with Acute Care: Rehab Liaisons

- Post-Acute Planning: Care Continuum Oversight, System-Wide Communication, Discharge at Admission,

- Documentation Improvement: Hardwired Coding Protocols External Strategies

- Outreach Efforts: Targeted Mass Media Marketing, Aggressive Market Expansion, Outreach “Coordinators”


- Specialized Branding: Centre and Staff Credentialing, Leveraged Specialty Care, Published Outcomes Data

- Facility Design: Physical Amenities,

- Technology Enablers : Stroke-Focused Interventions Consumerism

- Redefining care settings to better focus on the needs of seniors

- Better community and home integration, shifting away from facility-centric models

- Shorter stays, reduced emphasis on long duration and inpatient care

- Driving process change in response to baby boomers expectations: Recognizing lifestyle choices (Wellness and active living focus); Pampering (spa options, massage therapy, meditation); Responding to demand for add-on services

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Smoother Transitions Better Outcomes · Smoother Transitions Better Outcomes Building a Framework to Rethink Rehab ... together collectively to keep people healthy, help them get