ALC Transition and Flow Task Group
Framework for Reintegration Units in TC LHIN
June 2017
TC LHIN’s Definition: Reintegration
Units (RIU)*
An active fluid model based in the community
that specializes in the transition of patients
from hospital and community who are ALC or
at risk of ALC
• To help support development of a
comprehensive individualized care plan
(addresses health/behavioural/social
determinant needs)
• To provide intense specialized supports
to develop, as required, behavioural
support plans, care coordination,
socialization, reintegration to « bridge
the gap » to more permanent housing
Characteristics
Reintegration* strategies/models provide
temporary solutions to support transition
and flow):
•
Reduces bottlenecks and addresses
seasonal capacity challenges when a
permanent solution is not immediately
available.
•
Provides services on a temporary basis to
patients (while continuing to work on
creating more permanent solutions).
•
Provides a good focal point for integration
and coordination of services among
different providers across the continuum of
care
* Note: The Toronto Central LHIN has used the terms “reintegration units/programs” and “transitional units/programs” interchangeably.
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Characteristics of TC LHIN Patients designated ALC
Medical needs with a range of
conditions successfully managed
(e.g. nursing medical follow up,
PT/OT, non-weight bearing,
wound care, complex
comorbidities and active
treatment)
Complex behaviour (e.g.,
abuse to property, history of
aggressive behaviour, sexually
inappropriate behaviour, risk of
AWOL, history of arson, need for
locked unit)
Impairment with
ADLs/iADLs/Adaptive functioning
 Medically stable
 Cognitive impairment
 Intellectual disability
 Brain Injury
 Dementia
 High physical and social supports needs
 Needs for housing
 Need for supports with medication
 Substance use needs
Patients often present with
multiple comorbidities and
complex social needs
TC LHIN ALC Task Group on Transition & Flow: Current Strategy on Short-Stay
Reintegration Unit (RIU)
Short Term
(early wins)
• November 2016 to March 2017
• Opened 20 Short Stay Reintegration Beds - linked to the seasonal ALC surge/Flu Season (Oct -April)
• Undertook a current review of all Reintegration Beds and services (Community Convalescent Beds, MHA Reintegration Units, other community
interim/Short stay beds)
• Re-purposed9 Community Convalescent Care beds at St. Hilda’s into “Short Stay Reintegration Beds” year-round as from April 24, 2017
• January – July 2017
• Built on previous investments in RIU beds:
• Developed admission criteria and iterative processes (including staffing model, surge capacity) for transitioning appropriate patients to appropriate
beds/services
•
Confirmed the program description (staffing, services) and value for money for short stay reintegration beds based on patient needs
Medium Term
• Developed principles and guidelines for connecting reintegration services
(foundational)
• Focused on Reintegration beds at sub regions to meet population health needs
• Engaged HSPs and Key informants in discussion about long term strategy
Long Term
(transformational)
• July 2017- March 2018
• Broaden next phase to Undertake a review of all Reintegration Beds and services and Respite Beds, LTCH Convalescent beds, Assess and Restore
Beds)
• Build the transformational state that will review the future state of Reintegration Beds/services in TC LHIN- shared accountability for patients and
integrated funding model aligned with sub region, neighbourhood care teams and other ministry’s priorities
• Build a prototype that align reintegration beds across the continuum of care
Note: Sections highlighted in green have been completed
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Future State: Reintegration Units Planning Principles
1.
RIUs have to be planned as a Regional Program (i.e., not at sub-region level) and include a focus on short –stay and long-stay programs
2.
Future RIU planning must include clear eligibility criteria and focus on two distinct program models: medical and non-medical streams.
• Medical Model RIU planning should be preserved for clinically-appropriate patients and enhanced to allow it to broaden admission criteria
to address current restrictions (e.g., PIC lines)
• Non-Medical Model RIU Planning requires greater capacity (Note: As confirmed through current Test of Change at St. Hilda’s)
3.
Key challenges to be addressed in future planning include:
• Facilitating rapid access to Medical RIUs
• Providing efficient cross-support across RIUs to support clients with a combination of needs (e.g., Build capacity for non-medical RIUs to
address medical needs; build capacity for medical RIUs to address behavioural needs).
4.
Aligning the ‘system’ of RIU units/programs should begin with a focus on the following priorities:
• Shoring up and expanding existing models to support transition out of RIUs (e.g., securing housing; guidelines around short-term use of
shelters with right supports)
• Ensuring appropriate triage of patients to the correct stream
• Establishing a fast track process for centralized referrals to RIU by formalizing processes to share information (e.g., Community
Reintegration Rounds )
• Accessing team/client support to meet the care requirements of patients with a combination of needs (i.e., where the client is in the right
RIU but require other specialized supports to ensure all needs are adequately/safely addressed)
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Future State: Two Streams for Short-stay Reintegration Units
Reasons for admission
Medical Units
Non- Medical
Units
3 areas of focus:
1. Cognitive Impairment and
Dementia
2. Behavioural Supports
3. Attendant services
• To support patients who are non-weight bearing (NWB) prior to surgical
reassessment or transition to active rehab
• To gain confidence in ADLs (e.g., stoma, G-tube, hoyer lifts, transfers)
• To wait for acute/sub acute/conval /LTC transition
• To continue active wound care
• To continue active outpatient treatment (e.g., chemo)
• To address unique medical needs that are a barrier to discharge home
• To gain confidence in ADLs and IADLs
• To enable caregivers to be more confident
• To provide transitional support for those awaiting completion of
housing/caregiver needs
• To support patient waiting for LTCH on short wait list
• To support patients with the following challenges: Dementia and cognitive
impairment, Mental health and addiction, Behavioural, Wandering, Social
determinants and high personal care needs
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Future State: Short-stay RIU Medical and Non-Medical Streams
Eligibility Criteria
•
•
Characteristics for Eligibility &
Referral Criteria Governing All RIU
Units/ Programs
•
•
•
•
•
Focus on patients identified at risk of
ALC or designated ALC
Medically stable
Require activities with ADL and/or
iADL
Self-directed care not a requirement
(for most)
A defined maximum LOS (i.e, clients
supported for a limited time period
pending their next destination)
Will be supported by common processes:
Common Referral Form; Coordinated Access;
Transition/Discharge plan initiated through the
RIU process
•
Medical Units
•
•
•
•
Non- Medical
Units
•
Valid OHIP (for MD billing)
Patient is able to use call bell and/or
is safe with q4h checks
Maximum 6-week admission plan with
system agreement to repatriate if
necessary (i.e., no take back letters
needed)
Wandering (if secure unit in place)
No bed alarms/restraints (Note:
Patients’ inability to undo lap belts and
tilt wheelchairs >30 degrees are
considered restraints.)
Valid OHIP or Non-OHIP
Maximum 6 months admission plan
with transition to long stay
reintegration program
Wandering (if secure unit in place)
Care Model
24/7 Nursing*
In addition to:
• PSW, On call physician
• 3 x weekly medical clinics
• CNS (specialty wound care)
• 24/7 Pharmacy access
• CCAC in-house
• Access to prn CCAC e.g., Social
Work, SLP, etc.
• Physiotherapy (Mon.- Fri.
prn)/Occupational Therapy (prn)
• Activity Program (Mon.-Sat.)
Weekly labs
*24/7
To bePSW
require further discussion.
Care coordination/Social
Work
In addition to services related to:
• Dementia and Cognitive
Impairment
• Behavioural Supports
• Attendant services
*If patient not a TC CCAC client, referring organization to document patient/SDM is aware of potential several week waiting list for other CCAC support and family plan to manage this
upon discharge; Clear communication with patients and caregivers/SDM re: program expectations and transition next steps before, during and on transition from RIU
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Long stay Reintegration
•
Non-medical approach to community based support for high risk older adults and
seniors with complex needs who are able to continue living in their own homes or in a
Supportive Housing setting and direct their own care (or via SDM) - as long as there is
access to frequent, urgent and intense personal supports



Innovative regional service delivery model
24/7 support 365 days a year
Urgent response by trained PSWs allowing clients to immediately connect with
services in the event of an unplanned situation
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Current State: Long-Stay Reintegration Efforts to Support patients
designated ALC and/or at risk of ALC
Housing and services for
the uninsured
Short Term Reintegration
Transition from Hospitals
e.g.. SPRINT, WG, CCAC, LOFT,
Sunnybrook & Providence Test of
Change
Upstream intervention to reduce ED
and ALC
e.g. PSW/MH Test of change
Spoke services
Specialized services
e.g. MHA, language, dementia
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