  |
|
|
Understanding ALC and Facilitating Access to Rehab for ABI Patients Requiring Observers
|
|
|
The patient transitions working group is conducting an investigation to better understand the issues associated with ABI patients who are identified as being in need of an alternate level of care across acute care, rehab and complex continuing care programs. Through this process, the group is collaborating to problem-solve and facilitate access for ABI patients that are experiencing difficulty with transition.
Participating organizations are being asked to gather data about what contributes to an ALC stay for ABI patients (medical, physical, cognitive, and behavioural). We have a specific interest in understanding the behavioural challenges that impact ALC stays, even for those that are not referred to the Network because it is expected they will be declined.
Each week, the Toronto ABI Network facilitates a half-hour teleconference for participating members, in which the Network provides a bird’s eye view of the state of the waitlists for the rehab facilities. Every organization is asked to provide the following information which is then summarized and forwarded to all participants after the weekly teleconference.
Acute care:
- How many ABI ALC patients are currently in your facility on all acute units?
- How many have been referred to post-acute care? (inpatient rehab, residential, do not include those referred to LTC)
- What are their reasons for waiting? (medical, behavioural, psychiatric)
- How many ABI-ALC patient have you not referred?
- What are the reasons for not referring? (medical, behaviours, psychiatric)
- How many days have they been waiting with an ALC status?
Rehab and CCC units:
- How many ABI-ALC designated patients are currently in your rehab units waiting for post-rehab transfer?
- What are they waiting for? (LTC, assisted living, home)
- How many ABI-ALC designated patients are currently in your CCC units waiting for post-rehab transfer?
- What are they waiting for? (LTC, assisted living, home)
- What are the reasons for waiting? (medical, behavioural, capacity issues)
- How many days have they been waiting with an ALC status?
In addition to collecting the data on the ABI-ALC patients, another goal of the teleconference is to provide an opportunity for discussion and problem-solving about challenging patient transfers/discharges. The content of this discussion is recorded and themes and key issues are summarized to support the identification of service gaps which can then be used to support system planning.
Observer Pilot
This working group is also looking at implementing an Observer Pilot to look at cost sharing the resources of an observer for patients waiting for inpatient regular stream ABI rehab who previously could not be transferred due to use of an observer/sitter. Preliminary information suggests this approach can benefit both clients, in getting access to rehab earlier, and the system by reducing costs and enhancing patient flow. Organizations involved are working with the Network to finalize details for how the pilot will run and we are targeting implementation of the pilot in the New Year.
|
|
|
|
|
|---|
| |
