Fall Newsletter 2019 North West Regional Rehabilitative Care Program

Sharing Knowledge in Northwestern Ontario

Meet our Northwestern Ontario Primary Long Lake #58, Michipicoten, Pays Platt, Pic Mobert, Pic River, Care Teams! Rocky Bay, Sand Point, and Whitesand. Through the Sioux Lookout The North West region has two relatively recent Primary Area Primary Care Team Care Teams delivering rehabilitative care. Dilico (SLAPCT), community Anishnabek Family Care Primary Care Travelling Team members of all ages are able (PCTT) services communities across the Robinson to establish a continuous Superior Treaty Area East of Thunder Bay, and the Sioux relationship with healthcare providers for comprehensive, primary Lookout First Nation Health Authority Primary Care Team healthcare close to home. The collaborative team provides (SLAPCT) services communities across the far North. services for all age groups, with a specific focus on children and youth, preventative care and improved management of chronic The Dilico PCTT is a health initiative designed disease through both treatment and monitoring, as well as to bring quality care into our communities. support for clients in improving self-management skills. Based on identified gaps in First Nation healthcare provision, the focus of the PCTT has The intention of the service delivery model is to fill gaps in been to increase access to healthcare and services and to ensure that service providers are operating in a improve health outcomes for the First Nations population and the team environment provide wrap-around services and seamless primary care. The SLAPCT provides service to the residents of surrounding district by receiving an optimum level of care closer Indigenous communities within the catchment area, as well as to home. The allied health care team consists of Nurse the residents of Sioux Lookout. In addition to travelling to the Practitioners, Social Workers, Registered Practical Nurses, communities, the team services clients via tele-health and while Mental Health Registered Nurses, a Pharmacist, a Chiropodist, a they are in Sioux Lookout at their clinic on Queen Street. Registered Dietician, a Traditional Healing Liaison, and consulting Physicians and Psychologists. The integrated inter- As the team evolved, the model currently sees the SLAPCT professional team allows us to deliver a wide range of services divided into smaller teams/pods (three presently), which are including: scheduled medical appointments, physical responsible for the provision of care to a cluster of Indigenous assessments, treatments and referrals, chronic disease communities. The teams travel on a regular basis to communities management, specialized foot care, programming to support to provide team-based collaborative care including working with local resources at the nursing station which include nurses, healthy lifestyles, advice and counselling on diet and nutrition, physicians and community-based workers. The SLAPCT actively comprehensive medication management, and individual, family serves the 33 communities within their catchment area. and group counselling among others. Physiotherapy, Occupational Therapy and Speech-Language Pathology services For referrals to both programs, see the Regional Rehabilitative continue to be delivered through Home and Community Care. Care Program website at rrcp.sjcg.net in the Resources tab. Communities served include Gull Bay, Lake Nipigon, Lake Helen,

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Key Deliverables UPDATE for 2019-2020 Seniors Care Program for improved referrals to appropriate rehabilitation services for community-dwelling seniors with falls at The North West LHIN’s Rehabilitative Care Capacity Plan’s five the Emergency Department in Thunder Bay. key recommendations drive the work of the Regional Rehabilitative Care Program, ensuring the best use of our limited resources in fulfilling the goal of an integrated system of care. Join the NOSM Preceptor Database/ RRCP Email List Updates on the deliverables for the 19-20 year are: The RRCP partnered with NOSM to maintain a database of 1 Improve client experience and outcomes through rehab professionals in the Northwest. If you would like to stay implementation of the Rehab Care Alliance definitions up to date on the North West LHIN Regional Rehab Care framework to align rehabilitative care with the Program and NOSM’s initiatives and projects, please contact Denise Taylor at [email protected] or [email protected] provincial framework Published NWO rehabilitative care resources on the new rehabcareontario.ca portal and reviewed this and rrcp.sjcg.net Rehab Services Map at Physician Summer School (Sept 13-14); Validated our current and future states of rehab. 2 Develop a North Western Ontario-wide strategy to Recruitment of health human resources continues to be a focus improve client access and client transitions across the in Northwestern Ontario. Though we continue to have shortage continuum of rehabilitative care: for Physiotherapy in Sioux Lookout Meno Ya Win Hospital and SLFNHA Primary Care Team, Marathon, Red Lake, Geraldton, Implemented Patient Oriented Discharge Summary (PODS) on St. Joseph’s Hospital and Thunder Bay Regional Health Geriatric Assessment and Rehabilitative Care and Physical Sciences Centre, the RRCP would like to welcome the following Rehab (see further details); Continue to deliver and evaluate the new rehab professionals: Osteoarthritis Conservative Management pathway and GLA:D classes (see further details); Submitted recommendations to Dryden Hospital: Claire Goodin and Simonne Paine, PTs Non-Insured Health Benefits Medical Transportation Policy Meno Ya Win Sioux Lookout Hospital: Julie Bruckschwaiger, OT review. SLFNHA Primary Care Team: Isabel Diedericks & Cathy Wang, 3 Facilitate adherence to best practices for RDs; Stacey Lukye, Katlyn Glena & Shanjid Hasan, PTs; Julie rehabilitative care to improve client-centered care: Mahoney, Zara Sovani & Ela Rutkowski, OTs; Richard Provided 2 day Balance Course coinciding with Centre for Callewaert & Connor Howie, RAs; Sandi Pasternak & Reija Education and Research on Aging and Health: Frailty in Seniors: Karioja, RKins; Lauren Somers, SLP and Michelle Lockley, SW Supporting Resilience, Independence and Quality of Life. Keewaytinook Okimakinak Jordan’s Principle: Nav Thind, PT 4 Enhance utilization of innovative technologies to Lake of the Woods Kenora: Robert Sweeney, PT improve access to rehabilitative care services closer to Red Lake Hospital: Ranjan Sivakumar, PTA and Mike Poling home, particularly in remote and under-serviced areas: (doing contract PT) Review of needs to design an integrated referral pathway for Atikokan General Hospital: Jessica Gosselin, OT ambulatory rehabilitation services. LaVerendrye Hospital Fort Frances: Darcy Friesen, OT 5 Develop and implement data collection and Geraldton Hospital: Susan Black, OT; Stephanie Tozer, Kin evaluation systems for quality of care monitoring and St. Joseph’s Hospital: Jessica Popert, PT (3 South Physical continuous quality improvement to improve resource rehab); Meghan Jensen (Float, starting Jan) efficiencies for the provision of client-centered care: Co-leading Emergency Department Falls Prevention Rehabilitation Pathway (Rehab Care Alliance Pilot) with Regional

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Patient Orientated Discharge Summary (PODS) To date, PODS has been reviewed with 104 clients (of 109 eligible discharge) with 89% completion (target 100%) and an PODS was introduced at St. Joseph’s Hospital on the Geriatric average of 1.1 days before discharge (target 2 days). Client Assessment and Rehabilitative Care program (June 2019) and satisfactions has remained at 8/10 since the implementation of the Physical Rehabilitation programs (October 2019). “PODS is PODS; however, since PODS, clients have indicated improved a tool to help communicate discharge information for patients, understanding about their medications (86%-92%), increased presented in an easily understandable and usable form.” client/family involvement in discharge planning (26%-61%) and PODS is a provincial best practice, which supports the new reduced visits to the Emergency Department (11%-4%). Health Quality Ontario “Transitions from Hospital to Home” PODS will start on Medically Complex in January 2020. PODS is Quality Standard. PODS improves client/family communication provided to clients and families and a copy of the PODS is by ensuring they understand the following 5 pieces of scanned in the electronic medical record (Meditech). The next information: component of the Discharge Planning Toolkit will be the • Signs and symptoms to watch out for implementation of an Inter-professional Discharge Summary • Medication instructions available in print or Meditech with information for the next care • Appointments provider team (hospital, home and community care, nursing • Recommendations (Services, Equipment, Other) station, etc.) Implementation will be mid-end February 2020. • Telephone numbers and where to go for more information

GLA:D (Good Life with osteoArthritis in Educational Opportunities Denmark) Chronic Pain- ECHO The ECHO (Extension GLA:D is a conservative management, 6 week exercise and self for Community Health Care Outcomes) St. management program for people with hip or knee Osteoarthritis Joseph’s Care Group Chronic Pain and Opioid who are not appropriate or do not wish to receive a hip or knee Stewardship is a now offering modules in replacement. The GLA:D Ministry-funded pilot project with blocks of 2,3, and 4 weeks. To register, please visit Champlain and Toronto Central wraps up in March 2020. GLA:D www.echo.sjcg.net or email [email protected] programming is established in: Thunder Bay, Dryden, Kenora, Topics include: Atikokan, Manitouwadge, Terrace Bay, Nipigon and Marathon  Chronic Neuropathic & Nociplastic Pain (Dec 4, 11, 18) with programs pending in Fort Frances and Geraldton. The program has trained 31 professionals trained across all the sub-  Chronic Pain, Arthritis & Rheumatic Diseases regions, received 310 referrals, and screened 199 people. (Jan 8, 15, 22, 29)  Chronic Pain & Indigenous Health (Feb 5, 12, 19) Results of the program this year to date (n=77) include a  Chronic Pain & Diabetes (Feb 26, Mar 4, 11) completion rate of 83% and clinically significant improvements in the following: The Seating Process: Moving Theory to Practice +3.4 sit to stand reps in 30 seconds, A successful hands-on approach to the stages of clinical -3.2 seconds. In a 40m walk, and evaluation for seating and mobility interventions was held: -2.4 on a 10 point pain scale. Over 90% of the participants also noted that GLA:D helped them Tradeshow: November 28, 2019 to move more easily and complete their physical activities, 74% 2-day workshop & tradeshow: November 29-30, 2019 had less pain and 83% were better able to manager their Location: Victoria Inn, Thunder Bay, ON symptoms, and 79% were able to do the activities they enjoy. For more information email: For more information contact: Erin Puhalski, PT and GLA:D [email protected] project coordinator at [email protected]

Page | 3 St. Joseph's Care Group – North West LHIN Regional Rehabilitative Care Program Fall Newsletter 2019 Fall Newsletter 2019 North West Regional Rehabilitative Care Program Senior Friendly-7 Community Therapy Assistant Role Exploration On November 14, the North West Regional Geriatric The RRCP and Sioux Lookout First Nation Health Authority Primary Care Education Collaborative in Team were successful with partners Sandy Lake First Nation, Windigo partnership with the Centre Tribal Council, Eabametoong First Nation, North Caribou Lake First Nation, for Education and Research Northwestern Ontario Regional Stroke Network, Centre for Rural and on Aging & Health, SJCG and Northern Health Research, and Lakehead University to acquire $25,000 to the Regional Geriatric Programs of Ontario hosted a explore the role of a Community Therapy Assistant in the remote one-day education event: communities. The idea is there would be a local, full time trained “Frailty in Seniors: Supporting Resilience, “Community Therapy Assistant” to provide therapy activities assigned to Independence And Quality of Life” at Lakehead them by local visiting therapists, be the communication contact for rehab University’s Faculty Lounge, with 80 participants in when a client returns home, and to support tele-rehab activities in the Thunder Bay and 20 participants online via ZOOM community. Similar positions have been created in Northern Quebec (rehab from across the Northwest. Attendees learned about monitors) and Northern British Columbia. The grant will allow the team to the Senior Friendly 7 dimensions of care: Delirium, explore the need, the role, and the training requirements and delivery Loneliness, Mobility, Nutrition, Pain, Polypharmacy, preference with Elders and healthcare teams in the communities. and Urinary Incontinence. The theme of the day was RRCP Community Engagement Council Sub-Committee Jenga, emphasizing that the dimensions interact with one another. Sue LeBeau, Red Lake Margaret Cochenour Memorial Hospital

Laura Lee Barrie, Thunder Bay Regional Health Sciences Centre Brenda Deck/Kristen Miclash, Community Services for Independence- Practical Evaluation and Treatment of NorthWest Common Balance Disorders Brock Chisholm, Lake of the Woods District Hospital Supporting the Senior Friendly-7 theme, the next two Carolyn Freitag, Rehabilitative Care, St. Joseph’s Care Group (SJCG) days (Nov 15 and 16), Dr. Chantal von Schoenberg Chantal Bohemier, Réseau du mieux-être francophone du Nord de from Ottawa taught an energetic and insightful l’Ontario workshop on the evaluation of balance and treatment Denise Taylor (Chair), North West LHIN Regional Rehabilitative Care Program, ideas. The course was hosted at St. Joseph’s SJCG Hospital and 15 participants across the Northwest Esmé French, NWO Regional Stroke Network participated. Participants included PTs, OTs, and Janet Gordon/Cindy Hunt, Sioux Lookout First Nations Health Authority Kinesiologists. The course provided new outcome Jason Taddeo, Fairway Physiotherapy measures, a reminder of simple biomechanical principles and challenged the participants to Judy Mostow, Client and Family Partner challenge their clients further. The course also Jory Kettles, Sioux Lookout Meno Ya Win Health Centre emphasized the importance of physical activity Lucy Venne-Nabb, Dryden Area Family Health Team, Dryden Regional Health throughout the day and throughout our lifetime! Centre Motion is Lotion! Mary Adams, Rehabilitative Care Services, St. Joseph’s Hospital, SJCG Morgan Austin/Matt Mihalus, Spinal Cord Injury Ontario Michelle Strong, North of Superior Healthcare Group Samantha Moir/Beverly Kelly, North West Local Health Integration Network Scott Munro, Outpatient Rehabilitative Care, St. Joseph’s Hospital, SJCG Brigette Ouelett/Lucy Bonanno, Geraldton District Hospital Ted Scholten/Glenna Morand, Riverside Healthcare, Fort Frances Wendy McAllister/Craig Koslowski, North West Local Health Integration Network

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