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Streamlining Follow-up Services
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In order to limit duplication and to ensure the most effective use of our limited resources in providing follow-up to ABI patients post acute care; the Network facilitated a review of our current ABI follow-up services and worked with stakeholders to develop protocols for who will provide medical follow-up when a patient with ABI transitions from one level of care to another.
The following summarizes the agreement between acute care and rehab in relation to following ABI patients post acute care:
- If a patient from St. Michael’s Hospital is admitted to an ABI inpatient rehab program at Toronto Rehab, Bridgepoint Health or West Park Healthcare Centre, the Network will notify St. Michael's Hospital Head Injury Clinic to cancel their follow-up appointment.
- If a patient from acute care is discharged home to wait for rehab and subsequently declines an inpatient rehab bed offer, the Network will notify the respective acute care clinic to ensure a follow-up appointment is made where appropriate.
- If a patient is referred to either Toronto Rehab's or Bridgepoint’s Day Hospital, it will be the responsibility of the admitting program to notify the follow-up clinics of their intent to provide service to that patient.
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