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Task Group to Investigate Access Issue
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The Toronto ABI Network’s Systems Coordination Committee has identified an area of concern that we feel requires a targeted response.
Transitioning patients with an ABI from acute care facilities to rehab facilities has been noticeably affected by the consistent wait lists and limited bed capacity. Rather than a direct transfer to a rehab centre, patients are increasingly being repatriated to a community hospital or discharged home to wait for a rehab bed. This appears to be an issue that is unique to the ABI population, possibly due to limited capacity of inpatient rehab beds and the opportunity for ABI patients with good physical recovery to be managed at home in the meantime.
Once patients are at home, our data indicates that approximately 50% are declining admission to a rehab facility when a bed is offered. Families have a difficult time encouraging their loved ones to return to receive inpatient rehab and/or the patient and family do not immediately recognize the need for intensive rehab. Concurrently, rehab hospitals are reporting that patients who have been admitted from home are more likely to discharge themselves within 1-2 days. Anecdotally we are told that many of these people are recognizing a need for services after a period of time and are presenting to the CCACs, sometimes in a state of considerable distress.
A task group of providers representing the continuum across the ABI Network are meeting to identify the scope of this issue as well as to develop processes and strategies to increase the number of successful transitions from acute care to rehab care and to ensure appropriate follow-up for those individuals that do go home, or to a community hospital, to wait for inpatient ABI rehabilitation.
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