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Complex Continuing Care (CCC): Equitable Access and Care Transitions

For additional information on Complex Continuing Care and CCAC’s expanded role, please contact Arsalan Afzal, Project Manager Waterloo Wellington CCAC via email at arsalan.afzal@ww.ccac-ont.ca.

Improving care transitions for the residents of Waterloo Wellington is a priority for the WWLHIN and the WWCCAC. On October 16th, 2012 a significant milestone was achieved that addressed both of these critical needs.

All transfers to Complex Continuing Care (CCC) beds in Waterloo Wellington will now be managed through a centralized process at WWCCAC. Many months of collaboration between the CCAC and the hospitals has resulted in a robust and efficient new system to transfer patients from acute care beds to CCC beds. The new system means that all patients in Waterloo Wellington will have access to all CCC beds across the system in an equitable way.

As the lead agency for system navigation, care coordination, and transitions, WWCCAC is well-positioned within the local health system to manage the new CCAC referral system. This new role is part of a suite of expanded placement roles for CCAC. Earlier this year, CCAC assumed exclusive responsibility for referrals into Adult Day Programs and we look forward to adopting similar roles with respect to rehab beds and supportive housing units in the months to come.

These four new placement and referral roles highlight our commitment to ensuring equitable access and smooth care transitions for all residents of Waterloo Wellington. Restorative Care Brochure - can be found on the publications page.

CCC Webinar Thursday, November 22nd

View the PowerPoint presentation

 

CCC Programs

Amalgamation of FEU Restorative Care Working Group Recommendations

Complete Document.pdf

Response to Restorative Care Review May 2012: Amalgamation of Restorative Care and Functional Enhancement Units Recommendation from Complex Continuing Care Working group

Background Information

The Restorative Care program was developed in 2010 to support the Home First philosophy and is intended for individuals who have been deemed unable to return directly home after assessment in acute care. The populations served in the Restorative Care Program are those individuals who require and will benefit from a short period of transitional care of up to 90 days of low intensity goal oriented care to improve strength, endurance, or functioning so they can return home in the community. The Functional Enhancement Program is considered part of the Complex Continuing Care (CCC) programming and it also provides a moderate to low intensity rehabilitation programming for stable patients that require care that cannot be provided at home or in the community. The target length of stay for this program is currently less than 60 days. Appendix 1a, 1b, 1c contain the current program description/criteria and transition framework for eligibility into each program.

In early 2012, the Restorative Care Program underwent a thorough evaluation which resulted in a list of recommendations to be implemented by the WW LHIN-wide stakeholders geared at improving the success of the Restorative Care Program.  Furthermore in early 2012, the Expanded Role initiative for CCAC which builds on the legislative changes to the Community Care Access Corporations Act (2009) began engagement session with stakeholders. A Complex Continuing Care Working Group was developed to involve stakeholders and design LHIN-wide endorsed policies for consistent application with respect to Complex Continuing Care. The Working Group includes representation from all WWLHIN Hospitals as well as WWCCAC. The working group decided to include the Restorative Care Program as part of the scope of the Expanded Role initiative for CCC.

Recommendation from Complex Continuing Care Working Group

The Restorative Care Program evaluation released in May 2012 was presented to the Complex Care Network. The report made multiple recommendations regarding programming and eligibility criteria. Among the recommendations, the report suggested the amalgamation of criteria and programming for Restorative Care and FEU to create one LHIN-wide Restorative Care Program based on an ‘assess and restore philosophy’. The CCC Working Group identified that current patient populations and criteria for admission to FEU and Restorative Programs are closely aligned and that they can be fully amalgamated to provide seamless care to individuals accessing either of these programs. As part of this newly amalgamated program, the service provision within the therapeutic setting will need to include a therapy delivery model which can evolve according to the patient’s tolerance and be modified to maximize patient function. This will allow the delivery of care to focus on patient needs rather than provider needs. Staffing and funding models will require review and adjustment to meet the needs of this patient population. This model of rehabilitation therapy is consistent with the expectations articulated in the 2011/2012 funding letter for Restorative Care. The proposed program description includes the following amalgamated eligibility criteria:

  • The therapy model is based on the delivery of 15-30 minutes of moderate to low intensity therapy 3-5 days per week within a therapeutic setting that includes nursing rehabilitation, a community dining room, and opportunities for socialization

  • The patient demonstrates the potential to tolerate being up in the chair 1 to 2 hours, 2-3 times/day

  • Palliative clients with a longer life expectancy should be considered within the admission criteria as long as their medical treatment plan does not limit participation in the therapy program.

The current FEU admission criteria indicates a patient must be able to tolerate both 30 min of moderate to low intensity therapy five days per week and be up in a chair 2-3 times per day. The current Restorative Care admission criteria indicate the patient must be able to tolerate both 15 min of therapy activity three times a week and be up 1 to 2 hours, 2/3 times per day. The addition of ‘client’s potential’ as part of the newly amalgamated admission criteria is designed to incorporate both former groups of patients (FEU, Restorative Care) and the therapy model enables program flexibility to increase therapy intensity based on patient needs. The length of stay is clearly articulated as goal dependent up to a maximum of a 90 day stay for the new amalgamated program. Appendix 2a and 2b contains new program description/criteria for eligibility and new transitional framework for the amalgamation of these two programs.

The of the deliverables for the CCC Working Group is to develop a model that ensures the newly amalgamated program will allow for admission on evenings and weekends. This is consistent with expectations outlined in the 2011/2012 funding letter for Restorative care. This is also consistent with the recommendations of the Restorative Care Review completed in 2012.

Significant work has been completed by the Working Group to develop LHIN-wide CCC Guiding Principles. These principles are designed to communicate the expectations and agreed upon policies for the Complex Continuing Care Expanded Role Program. The document provides the endorsed:

Definition of Complex Continuing Care in Waterloo Wellington

  • Guiding policy and procedures

  • Mechanisms for equitable access to service, waitlist management

  • Metric tracking

  • Recommendation on technology enablers

  • Transfer of care procedure

  • Discharge planning and Problem Solving mechanisms 

 

Restorative Program Criteria and Transitional Framework - Oct16

Complete Document.pdf

Complex Continuing Care – Restorative Care (Combined Functional Enhancement and Restorative Care Programs)

Description: 

The Restorative Care program provides a moderate to low intensity goal-oriented rehabilitation program adults who are unable to return after assessment in acute care or those individuals who meet eligibility criteria from the community. The length of stay is goal dependent and is up to 90 days as required to improve strength, endurance, or functioning to ensure a safe transition to the community. Care plans are individualized and will be adjusted according to the individual’s tolerance level. Occupational therapy and physiotherapy is limited (the model is based on the delivery of 15-30 minutes of therapy 3-5 days per week) within a therapeutic setting that includes nursing rehabilitation, a community dining room, and opportunities for socialization.

Examples of individuals who may benefit from this program include those who have specific and realistic functional goals following:

  • An acute or prolonged illness that has left them de-conditioned

  • An injury that requires a prescribed period of non-weight bearing followed by a period of rehabilitation

  • Surgery where post-operative complications have prolonged functional recovery

Examples of individuals who may not be as successful in this program include those who are:

  • Demonstrating acute delirium, unresolved episodes of confusion, or cognitive impairment which limits their ability to participate in goal setting and/or the program

  • Palliative with a prognosis of less than three months

  • Primarily requiring respite care

Guiding Principles for Admission:

  • The referral source and the receiving service are responsible for ensuring that “the right patient is in the right bed, at the right time, with the right caregiver”.

  • The referral source has first-hand knowledge of the patient and is responsible for identifying specific, measurable, timely, and realistic goals and barriers to discharge.

  • The referral source is responsible for being knowledgeable of and consistently applying the referral criteria.

Determining Medical Stability – Restorative Care

  • A clear diagnosis and co-morbidities have been established

  • Medical conditions are stable and can be managed within the scope of an RN/RPN and do not require daily reassessments by a physician. (Physicians round once per week. . Physicians have 24 hour 7day a week on call coverage but may not see a patient for up to 72 hours following admission.

  • All abnormal lab values have been acknowledged and addressed as needed.

  • All consults and diagnostic tests for the purposes of diagnosis or treatment of acute conditions have been completed and reported or pending test results are not anticipated to dramatically change the treatment plan. A follow-up plan is in place at the time of the referral and follow-up appointments have been made at the time of discharge from the acute hospital

  • No acute psychiatric issues limiting the patients’ ability to participate in the program.

Determining if a patient is a candidate for the Restorative Care Program

Admission Criteria:

  1. Individuals with minimum age of 18 years.

  2. The individual’s needs are unable to be met with community resources (community services, outpatient therapy, CCAC services, and private pay services). Applications from the community should have current CCAC involvement and have maximized community-based services.

  3. The individual is medically stable; all acute medical issues have been resolved or reached a plateau.

  4. The individual or their substitute decision maker (SDM) has agreed to participate in the program and the individual demonstrates commitment, willingness, and motivation to participate in the program. The individual/SDM understands the regional nature of the program and the participant’s letter of understanding has been completed.

  5. There is reason to believe that, based on clinical experience and evidence in the literature, the individual is likely to benefit from the program.

  6. The individual demonstrates the potential to attain the identified functional goals and has the ability to participate and integrate new learning and skills into daily life.

  7. Functional and/or clinical goals have been established and are specific, measurable, realistic, and timely

  8. The individual has demonstrated potential to tolerate being up in a chair 2-3 times per day.

  9. The individual demonstrates sufficient cognitive ability to participate in goal setting and carryover new learning into their activities of daily living. For example, where a patient scores 15/30 or less on a MOCA or a delayed recall of less than 2/5, they may not be able to achieve carryover of new skills.

  10. The individual/SDM is committed to returning to the community, utilizing family and community support services as required.

  11. A realistic and viable discharge plan is identifiable and has been discussed with the individual.

  12. The individual’s special equipment needs have been determined.

  13. The treatment of other co-morbid illnesses/conditions does not interfere with the individual’s ability to actively participate in the program on a daily basis (for example, ongoing chemotherapy, radiation therapy, and dialysis which require frequent trips off site and may impact activity tolerance).

Exclusion Criteria:

  1. Those exhibiting violent behaviors with tendencies to harm self, others or property

  2. Unresolved delirium

  3. Acute psychiatric issues limiting the patient’s ability to participate in the program

  4. Exit-seeking behavior

  5. Individuals who have been assessed as palliative with a prognosis of less than three months

  6. In need of high-flow oxygen (> 4L/min) or humidified O2

 

General Complex Medical Criteria - Oct16

Complete Document.pdf

Complex Continuing Care – General Complex Medical

Description:

The General Complex Medical program offers a range of interdisciplinary therapeutic services for patients with complex medical conditions for which the care requirements cannot be readily met by community or LTC facility services. Complex Continuing Care co-payment may be applicable. Length of stay is dependent on individual patient needs.

Guiding Principles for Admission:

  • The referral source and the receiving service are responsible for ensuring that “the right patient is in the right bed, at the right time, with the right caregiver”.

  • The referral source has first-hand knowledge of the patient and is responsible for identifying goals and barriers to discharge.

  • The referral source is responsible for being knowledgeable of and consistently applying the referral criteria.

Determining Medical Stability - General Complex Medical:

  • A clear diagnosis and co-morbidities have been established.

  • All abnormal lab values have been acknowledged and addressed as needed.

  • Acute medical issues have been resolved or reached a plateau and are not fluctuating.

  • All consults and diagnostic tests for the purposes of diagnosis or treatment of acute conditions have been completed and reported or pending test results are not anticipated to dramatically change the treatment plan.

  • Medical conditions are stable and can be managed within the scope of an RN/RPN and do not require daily reassessments by a physician.

  • There are no acute psychiatric issues limiting the patient’s ability to participate in the program.

Determining if a Patient is a Candidate for General Complex Medical

Admission Criteria:

  1. Must be 18 years of age or older.

  2. Patient or substitute decision maker has consented to treatment in the program.

  3. Patient may have been assessed for LTC and has been deemed ineligible for LTC AND/OR :

    • Requires a long-term, progressive, goal oriented process to reach an optimal level of mental, physical, cognitive and/or social functioning

    • Requires technology-based care that exceeds services available in long term care or the community

    • Has a combination of multiple interacting and unpredictable chronic medical conditions, requiring skilled interdisciplinary team interventions

  4. Patient meets the criteria for medical stability.

  5. Patient’s special equipment needs have been identified.

  6. A follow-up plan is in place at the time of the referral and follow-up appointments have been made at the time of discharge from the acute site.

Exclusion Criteria:

  • Those exhibiting violent behaviours with tendencies to harm self, others or property.

  • Exit-seeking behaviour.

 

WW Rehab Transitional Framework 2012

Complete table can be found in this PDF document

 Referral Process

CCC & Rehab Information

Complete Document.pdf

Complex Continuing Care & Rehabilitation Beds – Referral Process & Information

Overview:

As part of the CCAC expanded role, Waterloo Wellington CCAC (WWCCAC) is now taking on the management of client access to Complex Continuing Care (CCC) beds including client assessment using standardized application form, eligibility criteria validation using standardized definitions, as agreed across WWLHIN, waitlist management, and assessment during complex care treatment, and discharge planning once a client is ready for discharge.

Restorative and FEU Amalgamation to form one Restorative Care Program:

The CCC Working Group identified that current patient populations and criteria for admission to FEU and Restorative Care Programs are closely aligned and that they can be fully amalgamated to provide seamless care to individuals accessing either of these programs.

What Will Change on October 16, 2012?

  • Restorative Care, Medically Complex and Chronic Assisted Ventilator CCC bed referral applications will be sent to CCAC.

  • CCC beds are regional beds and patients will have access to them based on a centralized regional wait list. Consent form is replaced by a Letter of Understanding to enhance understanding of available CCC.

  • The Restorative program will include both restorative and FEU beds.

  • CCC bed referrals will be made by using the application form (WW50). This is a regional form and will be used by all WWLHIN hospitals, community health teams and long term care facilities in the region.

  • Referral applications (Form WW50) will be completed and faxed to CCAC for Restorative Care, Medically Complex and Chronic Assisted Ventilator Beds. This application form can be completed for other types of Bed referrals (NBU, GAU & Rehab) but should be sent directly to CCC facilities.

  • A status of medical stability form (WW51) will also be completed at the time of Bed Offer.

  • Each application will have a designated primary and secondary contact person. These persons will ensure the completion of application form. They will be the contact for the CCAC care coordinator should additional information be required. They will also be responsible for completion of the status update form.

What Will Not Change on October 16, 2012?

Send fax application (Form WW50) for:

RestorativeCare, Complex Medical and Chronic Assisted Ventilator​

CCAC

GRH Freeport

CMH

SJHC

GRH Freeport​

​ ​

519 742 0635

519 749 4326​

519 740 4950

519 767 3434​

519 749 4326​
Neurobehavioural and Geriatric Assessment Units​
General Rehabilitation (CCAC Centralized Intake to start in December)​

 

* ​Note:  Do NOT use this application for palliative care referrals 

 

ADMISSION CRITERIA - RESTORATIVE CARE  (FORMERLY RESTORATIVE + FEU)
MEDICAL STABILITY CHECKLIST
Individuals with minimum age of 18 years.​A clear diagnosis and co-morbidities have been established. ​
The individual's needs are unable to be met with community resources (community services, outpatient therapy, CCAC services, and private pay services).  Applications from the community should have current CCAC involvement and have maximized community-based services. ​Medical conditions are stable and can be managed within the scope of an RN / RPN and do not require daily reassessments by a physician.  (Physicians round once per week.  Physicians have 24 hour 7 days a week on call coverage but may not see patient for up to 72 hours following admission.)​
The individual is medically stable; all acute medical issues have been resolved or reached a plateau.​All abnormal lab values have been acknowledged and addressed as needed.​
The individual or their substitute decision maker (SDM) has agreed to participate in the program and the individual demonstrates commitment, willingness, and motivation to participate in the program.  The individual / SDM understands the regional nature of the program and the participant’s letter of understanding has been completed.​All consults and diagnostic tests for the purposes of diagnosis or treatment of acute conditions have been completed and reported or pending test results are not anticipated to dramatically change the treatment plan.  A follow-up plan is in place at the time of the referral and follow-up appointments have been made at the time of discharge from the acute hospital.​
There is reason to believe that, based on clinical experience and evidence in the literature, the individual is likely to benefit from the program.​No acute psychiatric issues limiting the patients’ ability to participate in the program.​
The individual demonstrates the potential to attain the identified functional goals and has the ability to participate and integrate new learning and skills into daily life.​
Functional and / or clinical goals have been established and are specific, measurable, realistic, and timely.​
The individual has demonstrated potential to tolerate being up in a chair 2-3 times per day.​
The individual demonstrates sufficient cognitive ability to participate in goal setting and carryover new learning into their activities of daily living.  For example, where a patient scores 15 / 30 or less on a MOCA or a delayed recall of less than 2 / 5, they may not be able to achieve carryover of new skills.​
The individual / SDM is committed to returning to the community, utilizing family and community support services as required.​
A realistic and viable discharge plan is identifiable and has been discussed with the individual.​
The individual’s special equipment needs have been determined.​
The treatment of other co-morbid illnesses / conditions does not interfere with the individual’s ability to actively participate in the program on a daily basis (for example, ongoing chemotherapy, radiation therapy, and dialysis which require frequent trips off site and may impact activity tolerance.)​