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Sharing Knowledge in Northwestern Ontario

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Sharing Knowledge in Northwestern Ontario 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, Page | 1 St. Joseph's Care Group – North West LHIN Regional Rehabilitative Care Program Fall Newsletter 2019 Fall Newsletter 2019 North West Regional Rehabilitative Care Program 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 taylord@tbh.net or RehabStudies@nosm.ca 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 Page | 2 St. Joseph's Care Group – North West LHIN Regional Rehabilitative Care Program Fall Newsletter 2019 Fall Newsletter 2019 North West Regional Rehabilitative Care Program 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)
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