Overview of the North East Rehab Network

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Overview of the North East Rehab Network. NE LHIN HPAC Presentation September 17, 2010 Andrea Lee, Chair Jenn Fearn, Lead. Overview. Our membership Background info on the Network Recent projects Next steps. Membership. Formed in the Fall ‘06 with representatives from - PowerPoint PPT Presentation

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  • Overview of the North East Rehab NetworkNE LHIN HPAC PresentationSeptember 17, 2010

    Andrea Lee, ChairJenn Fearn, Lead

  • OverviewOur membershipBackground info on the NetworkRecent projectsNext steps

  • MembershipFormed in the Fall 06 with representatives from 5 NEO hospitals with designated rehabilitation beds (Timmins, Sault Ste. Marie, Parry Sound, North Bay, & Greater Sudbury)NEO Stroke NetworkNEO ABI Network NE LHIN (joined Fall 07)NE CCAC (joined Fall 08)

  • Membership14 members in totalAll resources are in-kindMeet regularly by teleconferencePreviously named the North Eastern Ontario Rehabilitation Network (NEORN)

  • Early Stages of the NetworkSignificant information sharing amongst members with respect to their programsDiscussion with respect to issues affecting the provision of optimum rehab in the northeastTerms of reference and workplan developedUnderlying premise - the establishment of linkages/ communication between acute care, inpatient rehab beds, and community-based rehab providers in NEO is crucial in order to provide integrated care

  • Early Stages of the NetworkInforming Administrators about our NetworkMet with NE LHIN Senior Management Team in Fall 07NE LHIN representative was appointed to our NetworkLetters sent to CEOs of all NEO hospitals and the NE CCAC in Winter 08Letters of support provided back to our NetworkLetter/workplan sent to NE LHIN CEO Spring 08

  • Integration Strategy HSIP SubmissionIn-person meeting for 1 day planning with facilitatorWebsite Coordinator position with administrative support

  • In Person MeetingPrior to meeting Stakeholders engaged in teleconferences

    Key meeting results Primary and secondary initiatives were determinedKey message developedPlanning report synopsis of past to future

  • InitiativesPrimary:System Referral and Access: Common Rehabilitation Referral FormRegional Inpatient Flow Website Development/Branding

    Other:AdvocacyTelemedicineEngaging the Community Link to other Networks

  • Key MessageThe North East Rehab Network supports the premise that rehabilitation is not just a destination or geographic location within a single organization. Early and effective rehabilitation is a philosophy of care that can and should occur at all points along the care continuum including acute care, long-term care and community based care.

    When effectively provided by an engaged interprofessional team, that includes family members, a rehabilitation focus will improve an individuals independence and function and can reduce ALC days, hospitalizations and demand for LTC beds. It should be supported by a system that endorses long-term follow-up and successful community re-engagement.

  • Recent ProgressCreation of:A common Inpatient Rehabilitation Referral Form to be completed for all external referrals to any of the 5 hospitals with designated rehab beds Summary table that provides a brief description of the rehab services available at each centreAudit form for data collection

    This referral form is to be used for all external referrals to designated inpatient rehabilitation beds in northeastern Ontario. There are five northeastern Ontario hospitals that offer these services details on the services can be found at the North East Rehab Network website (www.northeastrehabnetwork.ca) under the Admission and Referrals tab.

    This form is designed to be filled out electronically, then printed and faxed to the facility you have chosen. However, the option of printing out the blank form and filling it out by hand does exist. If when filling the form out by hand you determine that there is not enough room on the form for you to elaborate, please include your further information on another sheet of paper at the end of the referral form.

    Rehabilitation Criteria (all boxes must be checked to proceed with the application)

    FORMCHECKBOX

    The patient must have a physical impairment requiring rehabilitation OR have a known cognitive impairment requiring ongoing rehabilitation support or services.

    FORMCHECKBOX The patient is medically stable:

    A clear diagnosis and co-morbidities have been established

    At the time of discharge from acute care, acute medical issues have been addressed: disease processes and/or impairments are not precluding participation in rehab program.

    Patients vital signs are stable.

    No undetermined medical issues (e.g. excessive shortness of breath, falls, congestive heart failure).

    Medication needs have been determined.

    FORMCHECKBOX

    The patient or a substitute decision-maker must willingly consent to participate in a rehabilitation program.

    FORMCHECKBOX

    The patient must have the cognitive ability to participate in and benefit from a rehabilitation program.

    FORMCHECKBOX

    The patient or a substitute decision-maker and medical team have identified realistic, specific, measurable and timely, functional goals for the rehabilitation process.

    Please note: If you have any comments or suggestions on how to improve this form please direct your feedback to the North East Rehab Network - specifically Jenn Fearn, Lead, [email protected] or Andrea Lee, Chair, [email protected]

    Patient Surname:

    Demographics, Referral Information and Medical Information

    Surname:

    Given Name:

    Address:

    Date of Birth: (Y-M-D)

    City:

    Province:

    Gender FORMCHECKBOX M FORMCHECKBOX F

    Health Card #:

    Postal Code:

    Home Phone:

    Marital Status:

    Language(s) spoken: FORMCHECKBOX English FORMCHECKBOX French

    FORMCHECKBOX Other (Specify):

    Referring Institution:

    Contact Person for Clinical Information:

    Phone #: Pager #:

    Contact Person for Bed Offer: FORMCHECKBOX Same as above

    OR:

    Phone #: Pager #:

    Infections: FORMCHECKBOX MRSA+ FORMCHECKBOX VRE+ FORMCHECKBOX CDIFF FORMCHECKBOX None Known FORMCHECKBOX Other (Specify):

    Isolation Required: FORMCHECKBOX No FORMCHECKBOX Yes

    Referring Physician:

    Phone #: Fax #:

    Primary Rehabilitation Diagnosis:

    Date of Onset of Impairment: (Y-M-D)

    History of Presenting Illness:

    Current Active Medical Issues:

    Any pending investigations or follow-up? FORMCHECKBOX No FORMCHECKBOX Yes (Details):

    Past Medical History:

    Social Information

    Home living situation, living with:

    Support required before admission to acute care:

    FORMCHECKBOX Spouse/Partner

    FORMCHECKBOX Family (incl. extended family)

    FORMCHECKBOX Unknown

    FORMCHECKBOX Living Alone

    FORMCHECKBOX Other (Specify):

    FORMCHECKBOX None FORMCHECKBOX Spouse/Partner

    FORMCHECKBOX Family (incl. extended family)

    FORMCHECKBOX Attendant care

    FORMCHECKBOX Privately-funded care

    FORMCHECKBOX Meals on Wheels

    FORMCHECKBOX Spouse/Partner

    FORMCHECKBOX Roommate or Others

    FORMCHECKBOX CCAC

    FORMCHECKBOX Unknown

    FORMCHECKBOX Other (Specify):

    Pre-Admission Accommodation:

    Describe accommodation barriers that must be dealt with in order for patient to return home:

    FORMCHECKBOX House

    FORMCHECKBOX Apartment Building

    FORMCHECKBOX Long-term Care Home FORMCHECKBOX Homeless/Hostel

    FORMCHECKBOX Other (Specify):

    FORMCHECKBOX Residential Group Home

    FORMCHECKBOX Retirement Home

    FORMCHECKBOX Rooming House

    FORMCHECKBOX Unknown

    FORMCHECKBOX No barriers

    FORMCHECKBOX Stairs into dwelling

    FORMCHECKBOX Stairs to bathroom

    FORMCHECKBOX Stairs to bedroom

    FORMCHECKBOX Other (list):

    Expected discharge destination post rehab:

    FORMCHECKBOX Home FORMCHECKBOX LTC FORMCHECKBOX CCC FORMCHECKBOX Shelter/Hostel

    FORMCHECKBOX Assisted Living (i.e. seniors residence):

    FORMCHECKBOX Return to Referring Facility:

    FORMCHECKBOX Other (specify):

    Please comment if family is currently actively participating in the patients treatment and if transferred for further rehab would the family be able to participate?

    Has discharge plan been discussed with client/family? FORMCHECKBOX No FORMCHECKBOX Yes

    Have back-up plans been discussed? FORMCHECKBOX No FORMCHECKBOX Yes If yes, specify:

    Continence

    Bladder:

    FORMCHECKBOX Continent FORMCHECKBOX Incontinent FORMCHECKBOX Occasional Incontinence FORMCHECKBOX Catheter, Type:

    FORMCHECKBOX Other:

    Bowel:

    FORMCHECKBOX Continent FORMCHECKBOX Occasional Incontinence FORMCHECKBOX Total Incontinence FORMCHECKBOX Other:

    FORMCHECKBOX Colostomy (brand & size): FORMCHECKBOX Ileostomy (brand & size):

    Skin Status

    Skin Breakdown: FORMCHECKBOX No FORMCHECKBOX Yes

    All Stages/Locations: (only answer if you said Yes to Skin Breakdown)

    Treatment (Please describe treatment - including therapeutic surfaces)

    Swallowing / Nutrition

    Swallowing Disorder: FORMCHECKBOX New FORMCHECKBOX Chronic

    FORMCHECKBOX Not Applicable

    If new, has a swallowing assessment been completed? FORMCHECKBOX No FORMCHECKBOX Yes

    If yes, please attach report

    Method of Intake: FORMCHECKBOX ORAL FORMCHECKBOX PEG FORMCH