Coordinated Bed Access (CBA) is the single point of access for patients both within the Waterloo Wellington Region and Out of Region who are in need of post-acute care, including:
- Low Intensity Rehabilitation,
- Activation/Restoration (including Convalescent Care),
- Complex Medical Management,
- End-of-life/Pain & Symptom Management Complex Continuing Care, and
- Residential Hospice.
Accepted standard program criteria, referral tools and process, and discharge planning approach consistent with the Home First philosophy are used. See each level of care for materials.
Application and Acceptance to Wait List
To support patient flow and equitable access, patient application is to a level of care program rather than to a specific site. Application to a post-acute program will be made using the standard application form and standard program criteria. Program criteria for WWLHIN Rehabilitative Care programs are aligned with the Provincial Definition Framework for Bedded Levels of Rehabilitative Care (Rehabilitative Care Alliance, 2014).
Applications will be processed based on waitlisted date and will include referrals from community and out of region. Applications for Specialized Rehabilitative Care Programs (i.e., Stroke) will be processed based on clinical care pathways. Applications for Palliative Care Programs will be processed based on wait list date and prioritized based on the palliative prioritization framework.
An application is completed by a sending site and submitted to CBA. CBA reviews the application for field completeness and compliance with the Program Matrix. Patient application is accepted to the wait list when application is complete. CBA will inform the sending site if an application is incomplete in compliance with the Program Matrix.
Informed patient consent is required for application to a post-acute program, and for release of information to site(s) providing the program. Consent is obtained using the Letter of Understanding for the level of care to which the patient is applying. A standard patient letter is provided to the patient confirming the level of care recommended by the team, and the locations where this care is provided.
Bed Match, Medical Stability and Bed Offer
CBA will match a patient upon receipt of a bed vacancy, and release the application to the receiving site. The receiving site will to review the application for program appropriateness and contact the sending site to resolve any patient application concerns. The receiving site will use the contact person listed as the Bed Offer Contact (page 1 of Acute Care to Rehab and Complex Continuing Care Referral) or Primary Contact Person (page 1 of Activation/Restoration Referral) for communication with the sending site. If application concerns are not address, the process for patient bypass or refusal is followed by both sending and receiving sites (Appendix C).
Once application concerns are addressed, the receiving site will inform the sending site of patient acceptance to the program. The receiving site is then responsible for requesting medical stability:
- If admission is anticipated to be within in the next 24 hours, the receiving site will request medical stability at the time of patient acceptance.
- If admission is planned beyond the next 24 hours, the receiving site will contact the sending site 24 hours in advance of planned admission date to request medical stability.
The sending site is responsible for providing the medical stability to both the receiving site and to CBA within 3 hours of request by the sending site. The receiving site will make a bed offer by contacting the sending site, only upon receipt of medical stability. Receipt of medical stability by CBA will be considered confirmation of bed acceptance.
The sending site will inform patient/substitute decision maker of the bed offer. If the patient/substitute decision maker refuses transfer to the bed upon bed offer, CBA will proceed to the next person on the waiting list. The sending site will proceed with the discharge planning process with the patient to support transition to the most appropriate destination that will meet their needs other than post-acute bedded level of care.
Medical Stability & Transfer of Accountability
Patient medical stability is essential for bed offer and transfer to a program. The sending site is responsible for providing information on patient medical stability and change in status using the appropriate documentation. If the patient is medically unstable at any time while waiting, or at the time that medical stability is requested, the sending site will submit a Change of Status Form.
Medical stability confirmation is required to be submitted by the sending site within three hours of request. A medical stability form is considered valid for 24 hours. Transfer of Accountability is verbal communication between sending and receiving nursing staff; and is to occur just prior to the patient leaving the sending site.
If the patient is not medically stable at time of bed availability, the patient will be removed from the waitlist. The patient may reapply once medically stable and appropriate for the level of care.
279 Palliative Care Hospice-In-Patient Referral - Fillable_ENG.pdf