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Addressing Referral System Issues
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Recently the Systems Coordination Committee has been investigating current issues related to capacity and access for ABI rehab. A recent review of our data illustrates some of the issues we have been concerned about for a number of months:
- Wait times have increased for referrals from acute care to inpatient rehab (up by 5 days in 2007 as compared to 2006).
- There has been a change in length of time from date of injury to date of referral (decreased from average of 56 days in 2005 to 28 days in 2008), indicating referrals are being sent to the Toronto ABI Network in half of the time. Further, if we measure wait time from date of injury to date of admission to inpatient rehab, the time to admission has remained stable.
- The number of referrals sent to inpatient rehab but not accepted has increased (6% increase from 2005 to 2007).
- There has been an increase in the number of referrals for individuals with behavioural issues (9-20% in previous years to 27% in 2008).
- There are increasing lengths of stay in ABI rehab (from 50 days to 55 days).
- Discharge from inpatient rehab is made more difficult by lack of capacity in long-term care/community resources.
Another interesting finding is that while we consistently have a waiting list (often a substantial one of three weeks or more), on occasion there is concurrently capacity in the system. It is anticipated that the primary reason for this apparent disconnect is that there is not always a match between the patient needs and the available resources.
To determine an appropriate response, we have been considering the desired system goals which may require addressing:
- Increase appropriate access to inpatient rehab for more complex patient populations.
- Increase or reallocate resources of inpatient rehab to manage more complex patients.
- Increase access to outpatient rehab for patients coming from acute care that may not need an inpatient rehab program.
- Improve process issues that may be impeding patient flow (e.g., different approach to triaging referrals).
It is felt that all of these issues have merit and warrant a response; however, we recognize that we need to focus on those that will provide the biggest return and over which we can exert some control.
Therefore the following plan of action is being considered:
- Investigate the feasibility of conducting a pilot to evaluate the impact of sharing observers between acute care and inpatient rehab to facilitate access for patients who are rehab ready but continue to require an observer. The first step in this process will be to examine the scope of the issue. We will be asking acute care providers to track the number of patients they have who require a sitter but in all other ways are ready for rehab. This will begin to inform us of the potential to realize cost savings if we are able to move a patient (with their observer/sitter) into rehab sooner.
- Consider further stratification of the inpatient rehab wait list to maximize patient flow and ensure timely access for rehab candidates. We are in the process of developing transparent, evidence-based criteria that can support consistent and equitable decision-making.
- Standardize the language of referrals and information exchange through the use of measures such as the Disability Rating Scale (DRS) or Agitated Behaviour Scale (ABS).
- Investigate the feasibility and value of ABI System Rounds to support challenging referrals.
- Explore potential opportunities to reallocate resources, ensuring the best use of our limited resources.
The work of this committee is critical and the Network is committed to providing the necessary resources to move it forward. It is also critical that we have the support of our member organizations to make this a reality.
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