Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care

Introduction

This Referral Options resource was developed by the Rehabilitative Care Alliance (RCA) to assist referrers when looking for community-based rehabilitative care options for their patients/clients. It is a standardized provincial resource that provides information on rehabilitative care provided by Regulated Health Professionals (RHPs). Each LHIN will adapt the Referral Options tool to provide information on the resources within its region.

This resource provides information on publicly-funded community- and home-based programs that fall under the following 2 levels of rehabilitative care:

 Progression (i.e. to restore or maximize functional abilities)

 Maintenance (to prevent functional decline/injury or maintain functional performance)

Standardized provincial definitions for Progression and Maintenance levels of rehabilitative care have been developed by the RCA.

The Appendix Section of this resource includes:

 Key features of the Progression and Maintenance levels of rehabilitative care

 Standardized eligibility criteria for community-based, publicly funded rehabilitative care

For full details, see http://rehabcarealliance.ca/definitions-1 for the complete Definitions Framework for Community-Based Levels of Rehabilitative Care.

March 2018 P a g e | 1 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Referral Flowchart For Community-Based Rehabilitative Care* (MOHLTC/LHIN funded hospital-based outpatient/ambulatory programs, community clinics and in-home programs/services provided by Regulated Health Professionals)

Does the client require 24 hour nursing care Consider referral to a bedded (inpatient) level of and/or treatment plan & functional goals YES care. require daily, interprofessional intervention?

NO HOSPITAL-BASED Refer to most appropriate PROGRAMS/ Is the overall program to address goals of ORGs functional treatment based on patient/ trajectory of client complexity, service rehabilitative care Can the patient’s/client’s functional goal(s) delivery model (e.g. “PROGRESSION” be met in an outpatient/community setting Are the individual vs. group), (i.e. to restore or that is outside of the home? services approach (single discipline COMMUNITY YES maximize YES (i.e. patient is not home-bound due to YES available vs interdisciplinary team) and PHYSIO CLINICS functional overall functional status and/or underlying within the setting (e.g. hospital-based abilities)? medical condition that would compromise community? or community clinic). See Appendix for health status) Confirm that program's definition of admission criteria can meet Progression & Other Community the patient’s/client’s Eligibility Criteria Programs/Services rehabilitative care needs.

NO Refer to most appropriate FALLS program based on patient/ PREVENTION client complexity, the Is the overall functional service delivery model (e.g. Programs trajectory of rehabilitative individual vs. group) and care “MAINTENANCE” setting (e.g. hospital-based (i.e. to prevent functional Other programs/ or community clinic) that decline/injury or maintain services YES can best address goals of functional performance)? If a client lives: treatment See Appendix for At home – Refer for In home rehabilitative Community clinics / IN-HOME definition of Maintenance care services specialized rehabilitative Note: To find publicly-funded Programs In a LTCH – Contact the LTCH to discuss & Eligibility Criteria Exercise Classes (typically care (e.g. seating clinic, provided by non-Regulated referral to rehabilitative care services. prosthetic clinic etc.) Health Professionals), see services / other resources https://www.ontario.ca/ page/exercise-and-falls- prevention-programs. Also NO Consider other care plans see http://thehealthline.ca/.

*Refer to the RCA Definitions Frameworks for Rehabilitative Care for comprehensive definitions on levels of rehabilitative care. http://rehabcarealliance.ca/definitions-1

March 2018 P a g e | 2 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Rehabilitative Care Program Descriptions and Admission Criteria Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Hospital-Based Outpatient Programs/Services

Program Name: Regional Rehabilitation Outpatient Services Program (OT, PT, SLP, Hydrotherapy) Organization & Site: Hamilton Health Sciences- Hamilton General Site, Regional Rehabilitation Centre Location: 300 Wellington St. N, Hamilton, ON. L8L 0A4 Unique Admission Criteria: Adults with Acquired Brain Injury, Spinal Cord Injury, Stroke & Complex Musculoskeletal (MSK) conditions. Program Description: Overall Focus: To provide assessment and time limited treatment to:  Maximize recovery from recent acute event  Maximize functional abilities, and patient safety  Promote adaptation of/to home  Support transition to appropriate community-based programming  Support timely transition from acute care or inpatient rehab setting  Prevent admission or re-admission to acute or rehab hospital  Provide opportunity to learn/practice in a familiar, stimulating and supportive environment  Goal driven treatment based on measurable progress and functional change 1. NEURO (ABI/Stroke) Multi-disciplinary rehabilitation team, including Physiotherapists, Occupational Therapists, Speech-Language Pathologists, Physiotherapy Assistants and Occupational Therapy Assistants. Therapeutic warm hydrotherapy pool staff including Physiotherapist and Physiotherapy Assistant. Nursing is available by consult. Specific Target population: Medically stable community dwelling adults (18+)* who experienced a recent neurological event that required a hospital visit or admission. Neurological events include stroke (CVA), traumatic & non- traumatic acquired brain injury, brain tumor or similar central neurologic event. 2. COMPLEX MSK CONDITIONS/SURGERY Single-service Physiotherapy (Physiotherapist, Physiotherapy Assistants) with availability to consult/refer with Occupational Therapy/ Occupational Therapy Assistant. Therapeutic warm hydrotherapy pool staff including Physiotherapist and Physiotherapy Assistant. Nursing is available by consult. Specific Target population: Community dwelling adults (18+)* who are being discharged following a HHS hospital admission from acute care and/or rehabilitation and have experienced a recent complex orthopedic event (surgery or multiple traumatic injuries) and present with multiple co-morbidities or complications (e.g. infection, non-union fracture, multiple joint involvement, medical complications). A review by surgeon may be identified as likely to have poor outcomes and require intensive therapy not available in the community. Continued….

March 2018 P a g e | 3 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Program Name: Regional Rehabilitation Outpatient Services Program (OT, PT, SLP, Hydrotherapy) continued.

3. SPINAL CORD INJURY Multi-disciplinary rehabilitation team, including Physiotherapists, Occupational Therapists, Physiotherapy Assistants and Occupational Therapy Assistants. Therapeutic warm hydrotherapy pool staff including Physiotherapist and Physiotherapy Assistant. Speech-Language Pathology and Nursing are available by consult. Specific Target population: Community dwelling adults (18+ yrs)* with Spinal Cord dysfunction resulting in neurological deficits following traumatic injury, surgical interventions and/ or medical conditions affecting the spinal cord and complex generalized acute conditions affecting multiple limbs affecting functional abilities. This includes recent onset or recent change/ new related issues resulting in functional deficits. *individuals who do not require a bedded level of care. Hours of Service: Monday to Friday 8:00-5:00 Application/Referral Process: 1. Outpatient Referral form completed by referral source (http://www.hamiltonhealthsciences.ca/workfiles/rehab/outpatient_referral_form.pdf) Faxed to central intake office at 905-521-2359 *Referral sources: physician- please see below.

ABI or Stroke: Specialist

SPINAL CORD- Any physician

ORTHO- Physiatrist or Surgeon

2. Referral form reviewed by team at weekly Inter-professional Intake Meeting.

3. Accepted referrals: Booked by phone, or waitlisted, depending on current caseloads.

4. Declined referrals: Referral source and the patient are notified by letter as to the reason for being declined. Contact: Regional Rehabilitation Intake Office: Phone: 905-521-2100 x 40806 Fax: 905-521-2359

March 2018 P a g e | 4 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities)

Outside of Home

Hospital-Based Outpatient Programs/Services Hospital-Based Outpatient Programs/Services

Program Name: Program Name: Medical Daycare (MDC) Amputee Rehabilitation Swallowing Clinic Organization & Site: Organization & Site: Hamilton Health Sciences – Hamilton General Site Hamilton Health Sciences – McMaster University Medical Center Location: Location: Regional Rehabilitation Centre 1200 Main St W, Hamilton, ON L8N 3Z5 300 Wellington Street North, Hamilton, ON, L8L 0A4 3V1/ENT Unique admission criteria: Unique admission criteria: Assessment in the Amputee clinic to determine readiness to participate 18 and older, referred within HNHB LIHN Sitting tolerance must be 2 hours to participate in therapy Program Description: Independence in standing pivot transfers Pediatrics and Adults Outpatient only Patient goals include a desire and motivation to use a prosthesis SLP in collaboration with Diagnostic Imaging (D.I.) Techs and Radiologists. Residual limb must be in a condition to allow prosthetic fitting Hours of Service: Program Description: Monday to Friday 8:30 to 4:00 A program for adults who have recently experienced an amputation to: Achieve ambulation; Practice Application/Referral Process: functional ambulation activities; Practice functional activities of daily living; Have necessary equipment Physician referral with Mandatory completed and signed D.I. requisition for discharge identified and prescribed. Contact: Interprofessional team comprised of physician, prosthetist, physiotherapists, occupational therapist, SLP OTA/PTA, nursing, social worker, recreational therapist, dietician, pharmacist Phone: 905-521-2100 ext. 77065 Hours of Service: Monday to Friday 9:00 to 4:00 Application/Referral Process: Centralized Intake Process through HHS Intake Office. Referral Form: HNHB LHIN Acute to Rehab and Complex Care (CCC) Internal: Physician emails Intake Office – who create an inpatient referral form External: Referral form faxed to HHS intake office Refer to “Regional Rehabilitation Referral Process and Admission Criteria” Contact: Job Title – Clinical Manager 905-521-2100 ext 77573 [email protected]

March 2018 P a g e | 5 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities)

Outside of Home

Hospital-Based Outpatient Programs/Services Hospital-Based Outpatient Programs/Services

Program Name: Program Name: Hand Therapy Program Bariatric Program Organization & Site: Organization & Site: Hamilton Health Sciences – Hamilton General Site Part of the Ontario Bariatric Network; St. Joseph’s Healthcare Hamilton West 5th Campus Location: Location: West 5th Campus Regional Rehabilitation Centre 100 West 5th Street, Hamilton, ON L9C 0E3 300 Wellington Street North, Hamilton, ON, L8L 0A4 Medical Outpatient Department, Level 0 Block C Unique admission criteria: Unique admission criteria: Program Description: Patients requiring treatment for obesity. Admission criteria: adult population, body mass index Services acute traumatic hand injuries and post-surgical hand cases. This includes (but is not limited (BMI) equal to or greater than 30 with co-morbidities related to obesity. All patients are to) crush injuries, tendon lacerations, fractures, burns, amputations, nerve lacerations, brachial plexus referred through the provincial Bariatric Network. injuries and CRPS. Caseload is predominantly adult population, however, will see complex pediatric on Program Description: a case-by-case basis. Clinic follows a hand therapy model of care, with services delivered by http://www.ontariobariatricnetwork.ca/ and www.stjoes.ca Occupational Therapy and Physiotherapy Program provides medical or surgical treatment for obesity for the adult patient population. Hours of Service: Who provides service (e.g., interprofessional team, physiotherapist). Care is provided by a Monday to Friday 7:30 to 4:00 diverse team: Nursing, Registered Dietition, Social Work, Occupational Therapist, Psychologist, Application/Referral Process: Internist, Surgeon, specific clerical support staff. Referrals are accepted from specialists including plastic surgery, orthopedics, rheumatology, Hours of service: neurology. Referrals from GP.’s will be considered on an individual basis. 0800-1600 Monday to Friday with some extended service on week-days. Referrals can be faxed in to the clinic to be triaged by the therapists. Referring specialists can also call Application/Referral Process: in to discuss with therapists All referrals must be submitted through the Ontario Bariatric Network Contact: Contact: Hand Therapy Clinic Business Clerk Clerical Support Staff Phone: (905)521-2100 ext. 40578 General Information: 905-522-1155 Ext 33240 Fax: (905)527-0338 Information and Referral Specialist 1-800-810-0000

March 2018 P a g e | 6 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities)

Outside of Home

Hospital-Based Outpatient Programs/Services Hospital-Based Outpatient Programs/Services

Program Name: Program Name: Occupational Therapy Outpatient Hand Therapy Program Respiratory Rehabilitation Program Organization & Site: Organization & Site: St. Joseph’s Healthcare Hamilton, Charlton campus St. Joseph’s Healthcare Hamilton (Charlton Campus) Location: Location: 50 Charlton Ave E, Hamilton, ON L8N 4A6 8th floor Juravinski Tower Occupational Therapy Department 50 Charlton Ave E. L8N 4A6 Level 0, Bishop Dowling Wing Unique admission criteria: Unique admission criteria: Chronic lung disease (COPD, ILD, etc.) Patients requiring treatment for hand trauma or conditions affecting hand function requiring Program description: specialized splint management or therapeutic intervention. Admission criteria: All patients must be http://www.stjoes.ca/hospital-services/chest-program/respiratory-rehabilitation The referred through the specialists in plastic and reconstructive surgery and orthopedics from St. Joseph’s Respiratory Rehabilitation Program is a hospital-based outpatient program consisting of 8 weeks Healthcare or regional partners. of exercise and education classes. These will help you understand and manage your lung Program Description: disease, learn proper use of medications, breathe better with an individualized exercise plan, Focus of the service is to provide brief specialized intervention for hand trauma, post-surgical patients learn techniques for everyday activities, manage anxiety, and improve your quality of life. or patients with other hand conditions. Care is provided by an Occupational Therapist or an Exercise and self-management education for those with chronic lung disease. Occupational Therapist Assistant. Care is provided by a Respirologist, Physiotherapist, Physiotherapy Assistant, Respiratory Hours of service: Therapist, Occupational Therapist, Pharmacotherapy Specialist, Social Worker, Clinical and 0800-1600 Monday to Friday Health Psychologist, Dietician, Recreation Therapist, Speech-Language Pathologist, & various Application/Referral Process: learners. Referrals are accepted from specialists including plastic surgery, orthopedics, rheumatology, Hours of service: neurology. Referrals from GP.’s will be considered on an individual basis. 8 AM-4 PM Monday to Friday Referrals can be faxed in to the clinic to be triaged by the therapists. Referring specialists can also call Program days & cohort times: Each Mon, Wed, Thurs -- Morning cohort: 11 AM-2:30 PM, in to discuss with therapists. Afternoon cohort: 1-3:30 PM Contact: Application/referral process: Clerical Support Staff Fax a request for respiratory rehabilitation consultation to the front desk of Firestone Institute General Information: 905-522-1155 Ext 33290 for Respiratory Health (FIRH). Contact: Contact information 905-522-1155 Ext 33935

March 2018 P a g e | 7 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities)

Outside of Home

Hospital-Based Outpatient Programs/Services Hospital-Based Outpatient Programs/Services

Program Name: Program Name: Speech-Language Pathology Out-Patient Swallowing Clinic Technology Access Clinic Organization & Site: Organization & Site St. Joseph's Healthcare Hamilton/Charlton Site Hamilton Health Sciences, Ron Joyce Children’s Health Centre Location: Location: 50 Charlton Ave. E. Hamilton, On Ron Joyce Children’s Health Centre, 2nd Floor, 325 Wellington Street North, Hamilton, ON Speech Language Pathology Department Unique admission criteria: Level 0 Bishop Dowling Wing All Ages: TAC serves children and adults with neurological, developmental and/or multiple disabilities. Unique admission criteria: adult patients referred through the internist or Rehab Population: The Technology Access Clinic provides augmentative and alternative communication services for gastroenterologist. individuals to facilitate the communication of individuals who are not able to write due to a long-term physical Program Description: http://www.stjoes.ca/hospital-services/outpatient- disability and/or whose speech does not meet all of their communication needs. The client must have a physical services/swallowing-clinic . The Swallowing Clinic at St. Joseph’s Healthcare disability, be an Ontario resident and have a valid Ontario Health Card Number. Hamilton works in affiliation with McMaster University in Hamilton, Ontario. This is Program Description: a unique multidisciplinary clinic dedicated to understanding the causes of http://www.mcmasterchildrenshospital.ca/body.cfm?id=225 dysphagia. The clinic is conducted jointly by an internist and gastroenterologist, TAC Focus of Service includes the following: and a speech-language-pathologist. We are located in the Department of Speech- - Assess client needs and abilities for augmentative communication Language Pathology at St. Joseph’s Healthcare Hamilton. Our goal is to identify the - Determine eligibility for Assistive Devices Program (ADP) funding (individuals with a primary diagnosis of cause of a swallowing problem and to restore swallowing function to a level as Learning Disability are not eligible for ADP funding) normal as possible in order to improve quality of life and nutrition. Adult - Prescribe the most appropriate communication system and access method for clients population with swallowing difficulties - Recommend strategies for using the communication system Hours of service: - Train facilitators who assist the client in using their communication system Part-time hours/week varies with clinician availability - Provide ongoing support for the client, family, school and others to promote communication in all daily living Application/Referral Process: activities Physician referral required. A completed and signed St. Joseph’s Healthcare - Provide technical support in the client Hamilton Referral Form and Radiology Requisition must accompany all swallowing The interprofessional Team of TAC is comprised of Occupational Therapists, Speech and Language Pathologists, referrals. These forms can be obtained by calling the Department of Speech- Communication Disorder Assistants and Biomedical technicians Language Pathology at 905-521-6101. Please fax referrals to the attention of the Hours of service Department of Speech-Language Pathology at fax number 905-521-6159. 8:00-5:00 Contact: Application/Referral Process Speech-Language Pathologist http://www.mcmasterchildrenshospital.ca/workfiles/DPR/TAC/TAC%20Referral%20Form_with%20cover%20pg%20- 905 521-6101 %20Rev.%202016.pdf Contact: [email protected] 905-521-2100 ext. 7783

March 2018 P a g e | 8 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) In-Home Rehabilitative Care Programs

Program Name: Home and Community Care In-Home Rehabilitation Services

Organization and Site: Hamilton Niagara Haldimand Brant (HNHB) Local Health Integration Network (LHIN)

Location: In-home

Unique Admission Criteria: Patients referred to HNHB LHIN Home and Community Care are assessed for eligibility according to the following eligibility criteria and must meet all of the eligibility criteria to receive Home and Community Care services:

1. The patient must be insured under the Ontario Health Insurance Plan (OHIP). 2. The services must be necessary to enable the patient to remain in his/her home or to make it possible for the insured person’s return home from hospital or other institution. 3. Services must be reasonably expected to result in progress towards: • rehabilitation • maintenance of functional status or 4. The patient’s needs cannot be met on an outpatient basis and the patient is ineligible for other community/outpatient services. Notwithstanding this requirement, Home and Community Care services may be provided in the patient’s home or in a congregate or group setting. 5. The place where services are to be provided must have the physical features necessary to enable services to be provided. 6. Risk of serious physical harm to the service provider must not be significant. If significant, reasonable steps must be taken to reduce the risk so that it is no longer significant.

Program Description: Occupational Therapy, Physiotherapy and Speech Language Pathology are provided in a person’s home. Services promote patient and caregiver independence by providing support and teaching to patients and their families. Teaching and promoting independence are key components of the services provided. Service plan goals are time limited and focused on supporting patients and teaching the necessary skills to help transition them to self-care or family care as soon as possible.

Hours of Service: 8:30am to 8:30pm 7 days a week Application/Referral Process: Referrals: Anyone may make a referral with the patient’s consent. Office Location: 76 Victoria Street Simcoe N3Y 1L5 519-426-7400 Website: http://healthcareathome.ca/HNHB/en Contact: Information and Referral Specialist, 1-800-810-0000

March 2018 P a g e | 9 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Community Physio Clinics

Program Name: Community Physiotherapy Clinics

Organization & Site: Charlton Physiotherapy

Location: 230 James Street S., 3rd floor, Hamilton, L8P, 3B3

Unique Admission Criteria:  Must be referred by a physician or nurse practitioner In addition, patients must also be insured under Ontario Health Insurance Plan (OHIP) and be within one of the following categories: • aged 65 years and older; or • aged 19 years and younger; or • recently discharged as an inpatient from a hospital after an overnight stay in the last twelve months, and require physiotherapy for the condition, illness or injury directly as a result of the reason for the hospitalization; or • approved for funding under the Ontario Disability Support (ODSP) or Ontario Works (OW) programs.

Program Description: Aimed at addressing acute episodes or worsening of symptoms that lead to decreased function or mobility (e.g. debilitating event or disease (including chronic disease), pain, injury or surgical procedure). The person must be assessed by a qualified physiotherapist as experiencing acute episodes or worsening of symptoms that lead to decreased function or mobility. Treatment model: manages specific conditions / diagnosis, time limited, goal oriented care, education, home exercises, discharge to community programming or resources. Discharge occurs when: therapeutic objectives identified have been achieved; reasonably equivalent gains could be achieved through self-care or through an exercise, falls prevention, activation or similar program; or no further gains are likely to be achieved from continuing the physiotherapy services. Program is provided by Physiotherapist(s) and Physiotherapy Assistants. NOTE - treatment that maintains a level of function is not covered.

Hours of service: Mon - Fri 8am - 7pm, Sat 9am - 1pm

Referral process: Referral from a Doctor or Nurse Practitioner Call to book or use web form, http://hamiltonphysiotherapist.ca/

Contact: 905-528-5271 [email protected]

March 2018 P a g e | 10 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Community Physio Clinics

Program Name: Community Physiotherapy Clinics

Organization & Site: Hamilton Physio & Rehab

Location: 200 James St S #207, Hamilton, ON L8P 3A9

Hours of Service: Monday-Thursday 8:00 AM to 7:00 PM Friday 8:00 AM to 4:00 PM Saturday 9:00 AM to 2:00 PM

Referral Process: Referral from a Doctor or Nurse Practitioner Call the clinic number 905-529-0521 or Email [email protected] or visit www.hamiltonphysiorehab.com to book for assessment

Contact: Jhanvi Patel 905-529-0521 [email protected]

March 2018 P a g e | 11 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Community Physio Clinics

Program Name: Community Physiotherapy Clinics

Organization and Site: Innova Health Clinic

Location: 883 Upper Wentworth, Suite 303, Hamilton, ON, L9A 4Y6

Hours of service: Monday-Friday 8am-7pm

Referral process: Referral from a Doctor or Nurse Practitioner. Please call between 9am and 5pm and speak to reception to book an initial assessment. If you are calling to book for a family member please have all their information ready, including availability, so we can book the next available appointment.

Contact: 905-389-8772 [email protected]

March 2018 P a g e | 12 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Community Physio Clinics

Program Name: Community Physiotherapy Clinics

Organization & Site: Lifemark Physiotherapy - Hamilton Main East

Location: 200 James Street South, Suite 207, Hamilton, ON L8P 3A9

Hours of service: Monday - Thursday 8:00am - 6:30pm; Friday 8:00am - 4:00pm

Referral process: Referral from a Doctor or Nurse Practitioner Contact Clinic by Phone: 905-544-0053

Contact: 905-544-0053 [email protected]

March 2018 P a g e | 13 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Community Physio Clinics

Program Name: Community Physiotherapy Clinics

Organization & Site: Lifemark Physiotherapy - Hamilton Mohawk

Location: 210 Mohawk Rd E #3, Hamilton, ON L9A 2H6

Hours of service: Monday - Thursday 7:30am - 7:00pm; Friday 7:30am - 4:00pm; Saturday 9:00am - 12:30pm

Referral process: Referral from a Doctor or Nurse Practitioner Contact Clinic by Phone: 905-388-3902

Contact: 905-388-3902 [email protected]

March 2018 P a g e | 14 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Community Physio Clinics

Program Name: Community Physiotherapy Clinics

Organization & Site: PT Health - Queenston Physiotherapy

Location: 15 Mountain Ave S #105, Stoney Creek, ON L8G 2V6

Hours of service: Monday 8-7:30, Tuesday 8-4, Wednesday 8-7:30, Thursday 8-7:30, Friday 8-4

Referral process: Referral from a Doctor or Nurse Practitioner Contact clinic directly, contact Patient Care Centre or online web booking

Contact: 905-662-2011 [email protected]

March 2018 P a g e | 15 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Community Physio Clinics

Program Name: Community Physiotherapy Clinics

Organization & Site: PT Health - Victoria Physiotherapy

Location: 414 Victoria Avenue North, L2, Hamilton, ON L8L 5G8

Hours of service: Monday 8:00am to 6:00pm Tuesday 8:00am- 1:00pm Wednesday 8:00am- 6:00pm Thursday 8:00am-6:00pm Friday 8:00am- 3:30pm

Referral process: Referral from a Doctor or Nurse Practitioner Call or come into the clinic to book your appointment arrive 15 minutes early for paper work bring doctors note health card and proof of eligibility if applicable

Contact: 905-525-5572 [email protected]

March 2018 P a g e | 16 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Community Physio Clinics

Program Name: Community Physiotherapy Clinics

Organization & Site: PT Health - Mountain Physiotherapy

Location: 520 Upper Sherman Ave, Hamilton, ON L8V 3L8

Hours of service: Monday 8am-7pm, Tuesday 8am-7pm, Wednesday 8am-7pm, Thursday 8am-7pm, Friday 8am-1pm

Referral process: Referral from a Doctor or Nurse Practitioner Call 905 389 0143 ext 1 for new patients to speak to a call center agent who can book the assessment or call the same number with extension 2 for returning patients.

Contact: 905-389-0143 [email protected]

March 2018 P a g e | 17 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Community Physio Clinics

Program Name: Community Physiotherapy Clinics

Organization & Site: West End Physiotherapy Clinic

Location: 10 Ewen Rd Hamilton, Ontario L8S 3C4

Hours of service: Monday & Thursday: 8am- 4pm Tuesday & Friday: 8am -2pm Thursday: 8am -5pm

Referral process: Referral from a Doctor or Nurse Practitioner Walk in/call/email/doctor/surgeon referral. Contact: Ph: 1.905.524.2365 Fax 905-524-2367 Email: [email protected]

March 2018 P a g e | 18 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Community Physio Clinics

Program Name: Community Physiotherapy Clinics

Organization & Site: PT Health - Flamborough Physiotherapy

Location: 80 Hamilton Street N, Unit 5, Waterdown, ON L0R 2H6

Hours of service: Monday-Thursday : 8:00 AM-7:00 PM Friday : 8:00 AM-1:00 PM Saturday & Sunday : Closed

Referral process: Referral from a Doctor or Nurse Practitioner Walk in/call/email/doctor/surgeon referral.

Contact: Ph: 905-690-1033, (289) 812-4929 https://www.pthealth.ca/clinic/flamborough-physiotherapy-and-rehabilitation/

March 2018 P a g e | 19 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Other Community Programs/Services

Program Name : Program Name : North Hamilton Community Health Centre Occupational Therapy North Hamilton Community Health Centre Physiotherapy Organization & Site : Organization & Site : North Hamilton Community Health Centre North Hamilton Community Health Centre Location : Location : 438 Hughson Street North, Hamilton, ON L8L 4N5 438 Hughson Street North, Hamilton, ON L8L 4N5 Unique Admission Criteria: Eligibility Criteria: - Current Primary Care client of North Hamilton Community Health Centre - current Primary Care client of North Hamilton - referral from North Hamilton staff from other programs - client referred by North Hamilton staff from other programs - Community Referral which consists of : - community referral which consists of: - new immigrants and refugee claimants who face significant language or - new immigrants and refugee claimants who face significant cultural barriers language and cultural barriers - women and children living in women's shelters - women and children living in women's shelters - people belonging to the lesbian, gay, bisexual, transgender and queer (LGBTQ) community who - people belonging to the LGBTQ community who face barriers face barriers Program Description: Program Description: Physiotherapy Rehabilitation to address functional concerns relating to daily activities as a result of injury, illness, Hours of Service : disability, or chronic health conditions. Provided by Occupational Therapists. Monday / Tuesday / Thursday : 8:00 am - 5:00 pm Hours of Service : Wednesday : 8:00 am - 7:00 pm Monday - Thursday : 8:00 am - 5:00 pm Friday : 8:00 am - 4:00 pm Friday : 8:00 am - 4:00 pm Application / Referral Process : Application / Referral Process : Doctor or self-referral with Health Wellness Reception Doctor or self-referral with HW reception Contact : Contact : Health Wellness Reception Health Wellness Reception 905-523-1184 905 523-1184

March 2018 P a g e | 20 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care

Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Other Community Programs/Services

Program Name: Program Name: HHS Adult Wheelchair & Seating Clinic OTs2Go Organization & Site: Organization & Site: Hamilton Health Sciences- Hamilton General Site, Regional Rehabilitation Centre Hamilton Health Sciences, Centre for Healthy Aging, St. Peter’s Hospital Location: Location: 300 Wellington St. N, Hamilton, ON. L8L 0A4 Outreach Program, based out of St. Peter’s Hospital site Unique Admission Criteria: Unique Admission Criteria: Over the age of 18. Those needing assessment for assistive devices / Age 55+ / Living in the HNHB LHIN Require wheelchair and seating services of a complex nature Program Description: Program Description: This is a travelling seating and mobility service provided by occupational therapists, for adults 55+ The Adult Wheelchair and Seating Clinic provides wheelchair and seating assessment and who are experiencing age related disorders. Patients are seen in a home or community prescription services to adult clients with complex seating and positioning needs whose needs environment (not available to LTC residents) and receive: cannot be met by the community or HHS inpatient programs. The Seating Clinic has a dedicated  Complete Mobility Assessments wheelchair and seating focus, it is not diagnostic specific and will see people with a variety of  Mobility Device Prescriptions, as needed diagnoses, including but not limited to: Spinal Cord Injury, Acquired Brain Injury, Cerebral Palsy,  Funding Applications, where appropriate Multiple Sclerosis, ALS, Spina Bifida and other complex neurological and orthopedic diagnoses.)  Coordination of Repairs / Modifications Hours of Service:  Training on Safe Usage of Mobility Aids Monday to Friday 8:30-4:30 Hours of Service: Application/Referral Process: Monday to Friday 8am-4pm To access the services of the Adult Wheelchair and Seating Clinic, a referral form must be Application/Referral Process: completed in full, including client demographic and diagnostic information and physician signature, Clients can self-refer by calling 905-521-2100 x12424 / x12355 and faxed to the centralized intake office at Fax # (905) 521-2359. Referral Form can be accessed Contact: online: Clinical Manager, Centre for Healthy Aging and Specialized Geriatric Services, Hamilton Healthy (http://www.hamiltonhealthsciences.ca/body.cfm?id=1419) Sciences Contact: Phone: 905-521-2100 x12304 Job Title: Occupational Therapist & OTA/PTA Phone: 905-521-2100 Ext. 77128 Fax: (905) 521-2359

March 2018 P a g e | 21 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Progression (i.e. to restore or maximize functional abilities) Outside of Home Other Community Programs/Services

Program Name : Program Name: Caring for my COPD Occupational Therapy Services Organization & Site : Organization and Site: North Hamilton Community Health Centre Centre de Santé Communautaire Hamilton Location : Location: 438 Hughson Street North, Hamilton, ON 1320 Barton Street East, Hamilton, ON Unique Admission Criteria: Unique Admission Criteria: Individuals with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) Accept all francophone Occupational Therapy referrals that can be addressed in clinic or at client’s Program Description: residence Caring for my COPD is a 10-week program for individuals with modifiable COPD focusing on Program Description: improving the individuals' ability to manage their COPD. Adult Community Occupational Therapy Services (pediatric services planned ), Fall Prevention Provided by: Certified Registered Educator, Kinesiologist , Physiotherapists, Occupational Therapist, Program Dietitian, Social Work, Psychologist Hours of Service: Hours of Service : Monday and Wednesday 8:30am to 4:30 pm Tuesday and Thursday 8:30am to 2:30pm Monday - Thursday : 8:00 am - 5:00 pm Application/Referral Process: Friday : 8:00 am - 4:00 pm Referral by phone or fax to OT directly Application / Referral Process : Contact: You are welcome to refer yourself or a loved one to the program and we will contact your Primary Hamilton: tel: 905-528-0163 ext 3236, fax: 905-528-9196 Care Provider to ensure you are safe to participate. Or a referral to the program can be made by Website: one of your healthcare providers. We will contact you to start the program when we have your www.cschn.ca completed referral. Referral available on website. http://www.nhchc.ca/pages/index/Caring%20for%20my%20COPD Contact : Certified Respiratory Education Coordinator (CRE) for COPD 905 523-1184

March 2018 P a g e | 22 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Maintenance (i.e. to prevent functional decline/injury or maintain functional performance) Outside of Home Falls Prevention Programs

Program Name: Program Name: Falls Prevention Fall Prevention Classes Organization & Site: Organization & Site: Victoria Order of Nurses (VON) Canada Shalom Village Location: Location: Aberdeen Gardens Retirement Residence – 330 Dundurn Street South, Hamilton ON 70 Macklin St. North Hamilton ON L8S 3S1 (4th floor Ruth Sherman Centre) Amica at Dundas – 50 Hatt Street, Dundas ON Unique admission criteria: Amica at Stoney Creek – 135 King Street East, Stoney Creek ON Older adults living in the community, who are at risk of falls. Age: 60 + Caroline Place Retirement Residence – 118 Market Street, Hamilton ON Program Description: Chartwell Deerview Crossing Retirement Residence – 460 Rymal Road West, Hamilton ON Exercise classes for older adults with a focus on fall Prevention. Older adults living in the Schlegel Village Wentworth Heights – 1620 Upper Wentworth Street, Hamilton ON community, who are at risk for falls. Service is provided by Registered nurse/ senior exercise Seasons Stoney Creek – 8 Shoreview Place, Stoney Creek ON Specialist The Carlisle Retirement Residence – 467 Main Street East, Hamilton ON Hours of service: The Rosslyn Retirement – 1322 King Street East, Hamilton ON Tuesday and Thursday. 10:30-11:30 am (Class 1) or Dundas Retirement Place – 10 Hermkimer Street, Hamilton 11:30-12:30 (Class 2) for 12 week blocks *Please note the facilities listed are unable to answer questions regarding Falls Prevention Application/Referral Process: programming. Please contact the VON Coordinator with all questions regarding locations. Phone Club Fitness Centre: 905-529-1613 ext. 220 or [email protected] Unique Admissions Criteria: Contact: Ages 60 years and up or people under 60 with mobility issues. * All eligible members of the public Head Coach Club Fitness Centre are welcome, but must have own transportation and be able to participate in a group setting. 905-529-1613 ext. 220 & [email protected] Program Description: A 12-week, group-based program to reduce the incidence of falls and falls related injuries. This program includes two sessions per week, running 45 min each. Included in each session is an active exercise component to increase strength and improve balance as well as an interactive educational piece on falls risk factors and solutions. Programs are taught by a Registered Kinesiologist. Hours of Service: Varies at each location. Please contact the VON coordinator for schedule details. Application/Referral Process: Contact the VON District Coordinator for program locations, class schedules and registration. Contact: VON District Coordinator, Falls Prevention & Exercise Programs 905-529-0700 ext. 2282

March 2018 P a g e | 23 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care

Publicly-Funded Programs provided by Regulated Health Professionals for Maintenance (i.e. to prevent functional decline/injury or maintain functional performance) Outside of Home Falls Prevention Programs

Program Name: Program Name : Keeping Balance (Fall Prevention) Finding Your Balance Soyons actifs et Prévention des chutes (French) Organization & Site : Organization & Site: North Hamilton Community Health Centre Centre de santé communautaire de Hamilton Location : Location: 438 Hughson Street North, Hamilton, ON L8L 4N5 Royal Hamilton Light Infantry - 1353 Barton Street East, Hamilton Unique admission criteria: Centre de Santé - 1320 Barton Street East, Hamilton Over 50, fear /history of falls. Unique admission criteria: Program Description: None 12 week program consisting of education and exercise Program Description: falls prevention, over 50 The Exercise and Falls Prevention Initiative supports Ontario's Action Plan for Health Care, Provided by a Physiotherapist / Occupational Therapist specifically the focus on supporting seniors to stay healthy and stay at home longer, reducing the Hours of Service : strain on hospitals and long-term care homes. Services are provided by Health Promoters and Thursdays : 1:00-3:30 pm Occupational Therapists Application / Referral Process : Hours of service: Register with Occupational Therapist Varied, please contact the Health Promoter at CSCHN Contact: Application/Referral Process: Occupational Therapist Please contact the Health Promoter. 905 523-1184 Contact: Health Promoter 905-734-1141 ext. 2282 [email protected]

March 2018 P a g e | 24 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Maintenance (i.e. to prevent functional decline/injury or maintain functional performance) Outside of Home Other Clinics/Services (e.g. seating clinics)

Program Name: Program Name: Adult Chronic Pain Management Program Comprehensive Spasticity Management Program Organization & Site: Organization & Site: St. Joseph’s Healthcare Hamilton (King Campus) Hamilton Health Sciences- Hamilton General Site, Regional Rehabilitation Centre Location: Location: King, lower level, Special Programs Department 300 Wellington St. N, Hamilton, ON. L8L 0A4 Unique admission criteria: Unique Admission Criteria: Adults with a diagnosis of Chronic Pain. Patients must be referred by family and/or specialist Patients must be at least 18 years old with a diagnosis or condition that often results in spasticity physician only. No formal referral form at this current time. such as SCI, stoke, ABI, CP or MS. Program description: Program Description: The Adult Chronic Pain Program is an interdisciplinary program for Chronic Pain. Using the The focus of this service is to maintain and/or improve functional performance in mobility or biopsychosocial model to pain management, the program is led by a team of three Pain Physicians, a improved access for hygiene for the patient and/or the caregiver. Service is provided by an Psychologist, a Kinesiologist and a Registered Nurse. All patients must attend an orientation session interprofessional team consisting of a physician specialist, a nurse, an occupational therapist and that outlines the program’s treatment options and model of care before the first clinic visit is a physiotherapist often using oral and/or injected medication as well as other modalities to provided. At the first clinic visit, the patient will meet with all members of the team for initial optimize treatment. assessment and discuss treatment options. Treatment options may include: pain surgical procedures http://www.hamiltonhealthsciences.ca/workfiles/REHAB/WEB_Spasticity_Management_Brochur such as rhizotomies, epidural guided ultrasounds, radio frequency interventions, nerve block e_JKodis_Layout%201.pdf injections, 1:1 treatment sessions with the psychologist and/or Kinesiologist, enrolment and in the Hours of Service: CBT/Exercise group for Chronic Pain and/or mindfulness and/or sleep strategies groups. Clinics are held on Tuesdays, Wednesdays & Thursdays from 8:30am to 4:30pm. Hours of service: Application/Referral Process: 8 AM-4 PM Monday to Friday Referral is from other physicians as well as allied health who are expert in spasticity management Application/referral process: and are able to refer with the approval of the patient’s family physician. The referral form can be Referrals can be sent to the Chronic Pain Program directly at the contact listed below. The Chronic found online: Pain program administrative team will contact the patient and the referring physician of the patient’s http://www.hamiltonhealthsciences.ca/workfiles/REHAB/Comprehensive_Spasticity_Manageme orientation session date directly via telephone. nt_Program_Referral_Form_Layout%201.pdf Contact: Contact: Phone: (905)522-1155 ext 38611 CSMP Administrative Assistant Fax: (905)573-4832 Phone at 905-521-2100 Ext. 40803

March 2018 P a g e | 25 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care

Program Name: Program Name: Regional Rehab Respiratory/Pulmonary Function Clinic Michael G DeGroote Chronic Pain Clinic Organization & Site: Organization & Site: Hamilton Health Sciences- Hamilton General Site, Regional Rehabilitation Centre Hamilton Health Sciences, McMaster University Medical Centre Location: Location: 300 Wellington St. N, Hamilton, ON. L8L 0A4 Location MGD Chronic Pain Clinic – 4V Unique Admission Criteria: Unique Admission Criteria: Patients with: Neuromuscular (MS/MD/DMD/OHS/Central Sleep apnea); SCI; Amps; ABI; Greater than 18 years of age, people experiencing chronic pain for greater than 6 months that are Tracheostomy; Chronic ventilator failure/bronchial hygiene clearance issues able to attend and function in a group setting Program Description: Program Description: Respirology Consult: Airway clearance strategies including non-invasive techniques, Long-term Chronic Pain Cognitive Behavioral Program delivered by an Interprofessional Team mechanical ventilation, Artificial airway maintenance; Arm-ergometer exercise testing; Breath http://www.hamiltonhealthsciences.ca/body.cfm?id=3197 Stacking; In/Exsufflation (Cough Assist); Non-Invasive/Invasive assisted ventilation; Mouthpiece Hours of Service: ventilation; Tracheostomy assessment / optimization / tracheostomy changes / education; Long-term Monday to Friday 8am-4pm oxygen therapy; Inhaler optimization/education; Liaise with LHIN RRT, ADP, VEP, respiratory vendors Application/Referral Process: and Health Professionals to support community respiratory care; Diagnostic follow up with Referrals come from Family physicians or specialists. respiratory software; Full Pulmonary Function testing. See referral at: http://www.hamiltonhealthsciences.ca/body.cfm?id=3211 Who Provides Service: Respirologist & Registered Respiratory Therapist Contact: Hours of Service: Clinical Manager Tuesdays: 0830-1630 Phone: 905-521-2100 ext 73592 Application/Referral Process: Medical Consultation Request via Phone: 905-521-2100 Ext 40819 or Fax: 905-577-8233 Contact: Respirologist Admin. Asst 905-521-2100 ext. 40819

March 2018 P a g e | 26 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Maintenance (i.e. to prevent functional decline/injury or maintain functional performance) Outside of Home Other Clinics/Services (e.g. seating clinics)

Program Name: Program Name: Cardiac Health and Rehabilitation Audiology Diagnostic and Retail Services Organization & Site: Organization & Site: Hamilton General Hospital, Hamilton Health Sciences St. Joseph's Healthcare Hamilton/Charlton Site 237 Barton St. E, Hamilton, ON L8L 2X2 Location: Location: Level 0 Bishop Dowling Wing 3 East 50 Charlton Ave. E. Hamilton, On Unique Admission Criteria: Unique admission criteria: Patients with the primary diagnosis of heart disease either vascular or structural; Post MI, Post PCI, Referral required. Post cardiac surgery Program Description: Program Description: All ages-Hearing assessment and amplification needs. The care is proved by an Audiologist. The Cardiac Health and Rehabilitation Program is an Intensive program that focuses on cardiac risk https://www.stjoes.ca/health-services/outpatient-services/audiology-hearing-hearing-aid- factor management and lifestyle modification. Our program provides patients with the knowledge services and tools to effectively make good choices and develop lasting healthy behaviours to prevent further Hours of service: progression of their disease. Services include medical screening, education sessions for living with Monday, Wednesday, Thursday, Friday-8:00 am – 4:30 pm; Tuesday 8 :00 am -6:00 pm heart disease, nutrition topics, Stress management, social support, and exercise programs. Provided Application/Referral Process: by an interdisciplinary team including MD, RN, RPN, Dietician, Social workers, Kinesiologist For audiological assessments, a doctor’s referral is required either in writing or by phone. All Hours of Service: hearing aid work and auditory processing assessments can be self-referred. Our program is Monday to Friday: 0830-1630 registered with: Workplace Safety and Insurance Board (WSIB), Veteran’s Affairs (DVA) and Application/Referral Process: Assistive Devices Program (ADP). Referral from inpatient physician or unit Contact: Contact: Clinical Audiologist Cardiac Health and Rehabilitation Center Administrative office 905 521-6102 Phone: (905) 521-2100 Ext. 44388

March 2018 P a g e | 27 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Maintenance (i.e. to prevent functional decline/injury or maintain functional performance) Outside of Home Other Clinics/Services (e.g. seating clinics) Program Name: SAM Aphasia Programs Organization, Site & Location Hours of service: SAM East Aphasia Program – Good Shepherd Centres Hamilton Mondays: 8:00 am – 3:30 pm 1831 King Street E, Hamilton, ON Thursdays: 8:00 am – 3:30 pm SAM Flamborough Program - Good Shepherd Centres Hamilton Tuesdays: 8:00 am – 3:30 pm 1921 Snake Road, Waterdown, ON

Unique Admission Criteria: Adults 18 + years of age who:  Live with an acquired communication disorder such as aphasia, apraxia of speech, and/or dysarthria due to stroke, brain injury or brain illness  Individuals must be medically stable and live in the community  Completed or nearly completed their publicly funded speech-language therapy (i.e., inpatient, outpatient, CCAC)  Willingness to participate in Supportive Conversation Groups to improve communication  Able to participate in a group setting Program Description: Both SAM Aphasia Program Sites Offer:  Supported conversation groups run by a Speech Language pathologist, Communicative Disorders Assistant, Social Worker, trained staff and volunteers  Aphasia-friendly social, recreational, and exercise activities  A noon meal  Assistance with personal care including medications as required  Assistance with transportation  Support for caregivers  Aphasia education and partner Training  Ongoing social worker access www.adp-hnhb.ca Application/Referral Process: Contact the SAM Program Office at 905-525-5632 or the Hamilton Niagara Haldimand Brant Local Health Integrated Network (HNHB LHIN) at 905-523-8600 or 1-800-810- 0000 for more information regarding the application process. Contact Information: SAM Program Office Tel: 905-525-5632 Fax: 905-525-4149 Email: [email protected] Website: www.goodshepherdcentres.ca

March 2018 P a g e | 28 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care

Program: Goldies2Home – Day Program Organization and Site: Shalom Village Location: 70 Macklin St. North Hamilton ON L8S 3S1 (4th floor Ruth Sherman Centre) Unique admission criteria: Adults discharged from hospital Program Description: SupportGoldies2Home is a unique day program helping people return to independent living at home after early discharge from acute care, rehabilitation or convalescent care programs. This ambulatory convalescent program, partnered with enhanced CCAC services, will allow you to continue your convalescence from the comfort of your own home. Your program will include nursing, physiotherapy, recreation and other support to help you rebuild strength and regain skills to reduce your need for assistance. It is a community based rehabilitation program paced to your needs and promoting independent living.The Goldies2Home team includes a CCAC case manager, registered nurse, personal support worker, physiotherapist, physiotherapy aid, and therapeutic recreationists. A ratio of 1 staff to 5 participants ensures that you getthe support you need. The program is enhanced by in-home support, and is geared to the needs of people with limited endurance. Information sessions and support are offered to participants and family caregivers to ensure your move home is successful. Participants enjoy an active program with many opportunities for social interaction and recreational programs in addition to rehabilitation services. They have access to all amenities offered at Shalom Village including The Club Fitness Centre, Bubbi Bessie’s Café, Vicki’s Hair Salon and the Classic Theatre. Baths or showers are available, with assistance as needed, and professional foot care can be provided. A hot lunch and healthy snacks are served, with participants actively involved in meal preparation to help them prepare for independent living at home. Hours of Service: 9:00 a.m. to 3:00 p.m. from Monday to Friday. Application/Referral Process/Contact: For more information please call the Goldies2Home team at 905.529.1613 ext. 305 or e-mail [email protected]

March 2018 P a g e | 29 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Publicly-Funded Programs provided by Regulated Health Professionals for Maintenance (i.e. to prevent functional decline/injury or maintain functional performance) Outside of Home Other Clinics/Services (e.g. seating clinics)

Program Name : Program Name : Freedom to Be - Mindfulness Toolkit Mind Over Body - Chronic Pain Toolkit Organization & Site : Organization & Site : North Hamilton Community Health Centre North Hamilton Community Health Centre Location : Location : 438 Hughson Street North, Hamilton, ON L8L 4N5 438 Hughson Street North, Hamilton, ON L8L 4N5 Unique admission criteria: Unique admission criteria: Adults living in Hamilton who are interested in stress-free living, especially those struggling with Adults living in Hamilton who identify a struggle with living with chronic pain depression, anxiety, or chronic pain. Program Description: Program Description Open to all who experience chronic pain. A holistic group designed to help self-manage pain A free, community-based interactive group that meets weekly for 7 weeks and introduces a new tool lasting 3 or more months for developing your mindfulness and meditation skills each week. Space for individuals to learn self-management strategies to take control over their chronic pain Space for individuals to learn mindfulness and meditation skills to improve their ability to manage and be better able to manage their daily activities and participate in daily life stress, mood, anxiety, and pain issues. Provided by Social Worker / Occupational Therapist Provided by a Social Worker / Occupational Therapist Hours of Service : Hours of Service : Various 12 week sessions throughout the year Various 7 week sessions throughout the year Application / Referral Process : Application / Referral Process : Self-referral by phone; register with Social Worker Self-referral by phone; register with Social Worker Contact: Contact: Social Worker / Occupational Therapist Social Worker / Occupational Therapist 905 523-1184 905 523-1184

* Note: The availability of publicly-funded Exercise Classes (typically provided by non-Regulated Health Professionals) is region-specific. For HNHB LHIN programs, see link: http://www.hnhblhin.on.ca/goalsandachievements/integrationpopulationbased/olderadultstheirfamiliesandcaregivers/supportingseniorshealthandwellness/ExerciseFallsPrevention.aspx. For a general overview and links to region-specific programs, see links at https://www.ontario.ca/page/exercise-and-falls-prevention-programs. Also see http://thehealthline.ca/.

March 2018 P a g e | 30 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care Appendix Eligibility Criteria for Community-Based Rehabilitative Care* The community-based levels of rehabilitative care within this framework are to be applied to patients/clients who meet the following eligibility criteria:

 The patient/client has restorative potential*, (i.e. There is reason to believe, based on clinical assessment and expertise and evidence in the literature where available, that the patient's/client’s condition is likely to undergo functional improvement and benefit from rehabilitative care) or s/he requires rehabilitative care to prevent functional decline and

 The patient/client is medically stable enough such that s/he is able to participate in and benefit from rehabilitative care (i.e., carry-over for learning) within the context of his/her specific functional goals; and

 The patient/client has identified goals that are specific, measurable, realistic and timely.

*Restorative Potential Restorative Potential means that there is reason to believe (based on clinical assessment and expertise and evidence in the literature where available) that the patient's/client’s condition is likely to undergo functional improvement and benefit from rehabilitative care. The degree of restorative potential and benefit from the rehabilitative care should take into consideration the patient’s/client’s:

 Premorbid level of functioning  Medical diagnosis/prognosis and co-morbidities (i.e., is there a maximum level of functioning that can be expected owing to the medical diagnosis /prognosis?)  Ability to participate in and benefit from rehabilitative care within the context of the patient’s/client’s specific functional goals and direction of care needs Note: Determination of whether a patient/client has restorative potential includes consideration of all three of the above factors. Cognitive impairment, depression and delirium should not be used in isolation to influence a determination of restorative potential.

*See http://rehabcarealliance.ca/definitions-1 for the complete Definitions Framework for Community-Based Levels of Rehabilitative Care

March 2018 P a g e | 31 Hamilton Sub-Region Referral Options Resource for Community-Based Levels of Rehabilitative Care

☐ Key Features of Both Progression & Maintenance Focused Rehabilitative Care* Healthcare Professionals: Provided by or under the supervision of a minimum of one regulated health professional or by an integrated, interprofessional team of regulated health professionals in individual or group format to maximize community integration.

Transition Indicator: Rehab goals met or reasonably equivalent gains can be achieved independently or with caregiver or through self- care/wellness/health promotion classes or plateau has been reached

Medical Care: Medical care/management may be provided by a primary care practitioner (e.g. Family Physician, Nurse Practitioner) as well as by those focused on rehabilitative care (e.g. physiatrists, geriatricians, paediatricians and/or other specialists)

☐ Key Features of Progression-Focused ☐ Key Features of Maintenance-Focused Rehabilitative Care Rehabilitative Care Functional Goal: To provide assessment and time limited treatment Functional Goal: To prevent functional decline/injury or maintain through a single service or coordinated, inter-professional approach functional performance (e.g. strength, mobility, balance, falls

to restore or maximize functional abilities, promote adaptation prevention etc.) through individual assessment/treatment and/or of/to home, support timely transition from or prevent admission to periodic assessment/oversight of care plan by regulated health acute or rehab hospital or to provide opportunity to learn/practice professional/team in a familiar, stimulating and supportive environment Target Population: Individuals with reduced physical, cognitive Target Population: Individuals who after acute episodes or and/or speech-language functioning (e.g. neuromuscular, worsening of symptoms have decreased function and require musculoskeletal and cardio-respiratory etc.) who require rehabilitative care to achieve functional goals, increase self- rehabilitative care to prevent a decline in functional status and/or management skills and maximize community reintegration. to promote their capacity to remain at home. Individuals include Individuals who do not require a bedded level of care. those living in the community (home, retirement homes, LTCHs) who have functional goals that can be met by participating in group

intervention, which could include falls prevention classes.

*For full details, see http://rehabcarealliance.ca/definitions-1 for the complete Definitions Framework for Community-Based Levels of Rehabilitative

Care

March 2018 P a g e | 32