GREETINGS EVERYONE! Welcome to the fifth edition of the “InfoRehab Bulletin!’ This issue will update you on the progress we have made over the last few months. We will be highlighting some of the conferences we have presented at during the Fall and Winter as well as looking at the progress of our graduate students’ projects.

If you would like to be included in our e-mail distribution of the bulletin or would like further information on the material presented then please contact Sheila Bodemer at sbodemer@uwaterloo.ca

I hope you enjoy this issue, and look forward to continuing to work with you in advancing the use of health information in the rehabilitation of older persons.

Paul Stolee

March 1, 2011 Vol. 5

February 2009 Vol.1

BULLETIN

CANADIAN ASSOCIATION ON GERONTOLOGY Eleven InfoRehab team members from the Vancouver, Waterloo, and London sites attended the 39

th Annual Canadian

Association on Gerontology Conference in Montreal, Quebec from December 2-4, 2010. The team actively represented the InfoRehab Program of Research through attending and participating in various presentations throughout the 3 day event. Highlights include: 1. CIHR Student Poster Competition (MSc and PhD sessions)

Although we did not have a prize winning poster, our students proudly displayed their individual contributions to the InfoRehab project. Students reported there being intense interest in their work and received positive feedback and useful suggestions for moving their work forward. Pictured below from left to right: Jacobi Elliott, MSc Candidate, and Helen Johnson, MSc Candidate, University of Western Ontario; Justine Toscan, MSc Candidate; Josh Armstrong, PhD Candidate; and Brooke Manderson, MSc candidate, University of Waterloo.

Look for us at the following Conferences: InterACTION 2011 - Ontario Physiotherapy Conference, Ottawa, ON April 8-10, 2011 Canadian Geriatrics Society 31

st Annual Meeting Vancouver, BC

April 14 – April 16, 2011 Ontario Home Care Conference, Mississauga, ON May 25, 2011 Ontario Association of Community Care Access Centres Knowledge and Inspiration 2011 Conference, Toronto, ON June 22 – June 24, 2011 For more information check out our website: www.inforehab.uwaterloo.ca

2. InfoRehab Symposium The InfoRehab team presented a symposium consisting of 5 presentations revolving around data from each of the 3 investigative sites. The overall title for this presentation arose from a quote out of the Waterloo site pilot data: “Just Another Fish in the Pond”: Understanding Care Transitions for Older Rehabilitation Clients

“There’s more to health than just physical health. I guess that’s how I’m feeling here. You’re just another fish in the pond. And when they come along with the hook they’ll pull you up and if you’re trout they’ll put you one place, and if you’re bass they’ll put you another place, and if you’re pike, they’ll put you another place” — Mrs. Arthurs, (hip fracture patient on inpatient rehabilitation unit)

For titles and copies of the individual site presentations, please visit the “Publications and Presentations” tab on our website.

please visit our website.

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MEET OUR GRADUATE STUDENTS

MSc Candidates

Justine Toscan, MSc Candidate Justine’s research focuses on the informal family caregiver role during care transitions for older hip fracture and stroke patients. Using a Grounded Theory methodology, Justine has conducted 18 interviews with family caregivers and community Case Managers with the goal of uncovering family transitional care needs through their unique experiences of caring for their loved one. Through qualitative analysis of over 180 pages of interview text, Justine has developed a “Theory of Caregiver Needs for Supported Care Transition from Hospital to Home” which includes 3 levels: timeline of needs, physical needs, and emotional needs. Justine is currently working on obtaining feedback on the developed theory through a member checking process with the original interview participants.

Brooke Manderson, MSc Candidate Brooke's research is exploring the role of a system navigator for older adults. Her research will gather information from multiple perspectives and use a variety of data sources, including a systematic literature review, focus group interviews and in-depth interviews with a variety of health care consumers and providers. A critical analysis of collected data, using a framework derived from content analysis will seek to understand how older adults navigate the health care system, and subsequently explore the potential of a “system navigator” role to facilitate successful transitions across care settings. Finally, following a grounded theory approach, a model will be empirically derived to reflect what role system navigators may have on the experience of older adults navigating the health care system in Waterloo Wellington.

Jacobi Elliot, MSc Candidate Jacobi’s current research focuses on observing family caregivers during care transitions. Specifically, she is interested in the contributions that caregivers make to knowledge exchange between and within health care settings. Using an ethnographic approach, Jacobi has conducted several interviews with patients, family caregivers and health care providers. In addition, observation field notes and document reviews were completed at each transition. Thematic analysis of the data is being conducted to reveal the relationship between family caregivers’ knowledge exchange and smooth transitions for patients. She hopes to have her thesis completed by summer 2011.

Josh Armstrong, PhD Candidate Josh’s current research work involves quantitative analyses of data collected via the RAI-HC data system on clients in the Ontario Home Health Care system. The RAI-HC data system has been mandated for use for all home care clients expected to use home care services for longer than 60 days, which provides Ontario census type data on home care users. Currently, Josh is finishing a manuscript titled “Recognizing Heterogeneity in Patient Populations: Clustering Analysis of Rehabilitation Service Users in the Home Health Care System of Ontario”. In this project, we utilized a data mining technique known as k-means clustering in an attempt to further our understanding of the diversity found within the population of home care clients that utilize rehabilitation services (physical therapy and occupational therapy). In addition to this manuscript, Josh is currently working on his second comprehensive exam that will review the use of machine learning and data mining methods for the care of the elderly. For his dissertation, Josh plans to combine contextual knowledge with machine learning and data mining techniques to improve the understanding and delivery of rehabilitation services in the home care.

Helen Johnson, MSc Candidate Helen’s research focus is on information transfer and information exchange occurring through care handoffs being executed by rehabilitation professionals (physiotherapists and occupational therapists) across the care continuum of rural hip fracture patients. Key questions are: 1) What information do physiotherapists see as important to managing a hip fracture patient and optimizing care at points of transfer across the continuum of care? 2) What information do physiotherapists actually exchange across health care settings? 3) What are the facilitators and barriers to exchanging information through care handoffs to optimize rehabilitative care for frail elderly patients during points of transfer across the continuum of care? Ultimately, the key concept of interest is, “how well does a patient’s rehabilitative care pick up in the new setting from where it left off in the previous setting following a care handoff?” From a larger InfoRehab ethnographic study, Helen is in the process of thematic analysis of 55 interviews with patients, family caregivers and health care providers and observation field notes along with content analysis of relevant health care records documents. She hopes to complete her Master’s thesis by summer 2011.

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UPCOMING PUBLICATIONS and PRESENTATIONS Waterloo Site: Manuscript #1 Title: Care Transitions: The Lived Experiences of Hip Fracture Patients, Health Care Providers and Informal Caregivers About: This paper will present findings from the pilot research completed at the Waterloo site; specifically themes arising from interviews surrounding one patients transitional care experience, and lessons and challenges from this work Progress: Internal review process within Waterloo site Expected Submission: Early Spring Proposed Journal: Canadian Journal on Aging Manuscript #2 Title: Unclear Roles and Responsibilities: How are care transitions for hip fracture patients affected by unclear roles and responsibilities of the patient, their health care providers and family caregivers? About: This paper will align closely with the Waterloo site CAG symposium presentation and will focus on the issue of role clarity for multidisciplinary teams working towards integrated care within and between care settings during care transitions. Progress: First draft to be completed by Mid-March Expected Submission: Late Spring Proposed Journal: Journal of Qualitative Health Research Manuscript #3 Title: Predicting rehabilitation use in home care clients: an application of machine learning variable selection methods: About: The goal of this paper is to investigate which home care client characteristics included in the RAI-HC are most relevant in predicting rehabilitation use and to compare the items in the RAI-CA with those variables available in the full RAI-HC assessment. Machine learning algorithms were used and consideration is made for using these statistical techniques in planning rehabilitation services. Progress: First draft to be completed by Mid-March Expected Submission: Late Spring Proposed Journal: Journal of Clinical Epidemiology Manuscript #4 Title: Predicting functional outcomes for MSK patients receiving home care: does rehabilitation make a difference? About: This paper used multi-state Markov models to analyze the RAI-HC data to investigate the impact of OT/PT on functional outcomes for home care clients with MSK disorders. Progress: First daft to be completed by Mid-April Expected Submission: Late Spring Proposed Journal: To be determined Vancouver Site: Manuscript #1 Working Title: Strategies for Success: how healthcare providers are making transitions work About: This paper will present findings from key informant interviews with healthcare providers involved in hip fracture transitions across the continuum of care in Vancouver, BC. Analysis focused on creative strategies and facilitators to improve transitional care. Progress: Internal review process within Vancouver site Expected Submission: Early Spring Proposed Journal: Social Science and Medicine Manuscript #2 Working Title: Unrealistic patients: Discharge planning, healthcare decision making and older people About: This paper links key informant interviews with one patient case around discharge destination planning. In healthcare provider interviews a shared discourse of ‘giving options’ to patients is in contrast to observation and accounts about how discharge decision making actually happens in our field study. The contrast between what people think they offer and then what actually happens is used to explore how power, autonomy and beliefs about decision making are mobilized in a climate focused on economic constraints, risk and expertise. Progress: First draft to be completed by the end of March Expected Submission: Early Summer Proposed Journal: Social Science and Medicine

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UPCOMING PUBLICATIONS and PRESENTATIONS cont’d…

Vancouver Site cont’d… Manuscript #3 Working Title: Healthcare provider perceptions of family in post-operative hip fracture care transitions About: The Vancouver team has started coding data from the ethnographic study in relation to how healthcare providers perceive the family’s role in transitional care. Emerging themes are: families as a healthcare resource, expectations of families, what about those without families?, and barriers to communicating with families. Progress: First draft to be completed by the end of June Expected Submission: Late Summer Proposed Journal: TBA Manuscript #4 Working Title: Transfer of information within healthcare: An interdisciplinary perspective About: “Failures of communication in healthcare are well-documented and much has been written about problems in transfer of healthcare information within and between various health care settings. Despite the development of interventions aimed at improving information transfer, multiple barriers are consistently reported. The objective of this paper is to provide an interdisciplinary perspective on the transfer of information between healthcare settings. Such an analysis makes explicit the theories underlying previous examinations of the problem and ideally suggests an enhanced approached based on a new perspective informed by a synthesis of disciplinary approaches.” –Mary Egan, Kerry Byrne and Christine Ceci Progress: Collaborators have discussed a methodology for literature review and next steps Expected Submission: TBD Proposed Journal: TBD

The InfoRehab Phase II Planning Workshop will be held in April where investigators, collaborators and students will come together to brainstorm ideas

and strategies for the next phase of our research!

WE NEED YOUR HELP!

Please brainstorm ideas for the agenda of our upcoming planning workshop:

What types of things would you like to discuss?

Is there anything you want to learn more about?

Do you know any creative activities to engage our group? Send your ideas to Sheila Bodemer by March 21st, 2011: sbodemer@uwaterloo.ca

PHASE II

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WHAT WE’RE READING! Be sure to check out this interesting current literature that our group has been reading… Bone & Joint Health Network. (July 2010). Communique. Toronto, ON: Bone & Joint Health Network. Grandjean, C., Agazio, J., McMullen, P., Howie, W., Paterson, M., Dutton, R., Unsanit, P., Ekasingh, B., Buaboon, N. (February, 2009). The process of transitioning across levels of care among severely injured workers. SOJNR, 9 (1). Helfrich, D. C., Damschroder J. L., Hagedorn, J.H., Daggett, S.G., Sahay, A., Ritchie,M., Damush, T., Guihan, M., Ullrich,M. P., Stetler,

B.C. (2010). A critical synthesis of literature on the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Implementation Science, 5 (82).

Kane, R. L. (2011). Finding the right level of posthospital care “We didn’t realize there was any other option for him”. JAMA, 305 (3). Krist, A.H. & Woolf, S.H. (2011). A vision for patient-centered health information systems. JAMA, 305 (3). McMullan, J., McGlasson, R., Waddell, J., & Holmes, M. (2010). Final Report from the Ontario Hip Fracture Care Forum: Removing Access Barriers to Return People Home. Toronto, ON: Ontario Orthopaedic Expert Panel Canadian Orthopaedic Care Strategy Group. McMullan, J. (2008). An Integrated Model of Care for Patients with a Hip Fracture. Final Report Performance Improvement Fund. Toronto, ON: Total Joint Network. Schulz, R., Burgio, L., Burns, R., Eisdorfer, C., Gallagher-Thompson, D., Gitlin, N. L., &Mahoney, F. D. (2003). Resources for Enhancing Alzheimer’s Caregiver Health (REACH): Overview, site-specific outcomes, and future directions. Gerontologist, 43 (4).

The vision of the Informed and Linked Care Network for Canada’s Seniors (InfoLiNCS) is an effective and efficient health care

system that works for Canada’s seniors. The aim of InfoLiNCS is to develop a collaborative of researchers, practitioners, policy makers and inspired corporate partners to create innovative strategies, processes and technologies to transform care delivery to vulnerable seniors through enhanced health information exchange and more successful care transitions, across the continuum of care. Research and development activities will focus on creating system-level solutions which are transportable across disciplines and national boundaries. Currently, the network involves over 80+ confirmed academic collaborators, from 33 participating universities and research centres, and the involvement of 10 private and 40 receptor community partners across Canada. This network has expertise in academic disciplines such as gerontology, applied health sciences, engineering, computer science, health informatics, health services research, epidemiology, statistics, health economics, geography, environmental science, psychology, and sociology. InfoLiNCS will harness the clinical and research expertise of university and community based health care practitioners representing geriatric medicine, geriatric psychiatry, family medicine, nursing, and rehabilitation, to generate practice-based solutions to challenges related to information exchange and care transitions. Seniors and their care partners will also be actively engaged in building a deep understanding of the issues, generating ideas and providing feedback on network activities and outcomes.

This proposed network builds directly on the CIHR-funded “InfoRehab” research program which has involved over 30 researchers and collaborators across Canada. With a focus on rehabilitation services for seniors, findings from this research have reinforced the critical importance of effective information exchange, particularly during care transitions, and have identified numerous related deficiencies and challenges in the current health care system. If successful, an invitation to complete a full application for the InfoLiNCS network will be sent in March, 2011.

NEW! Networks of Centres of Excellence (NCE) 2012 Competition Entry Scientific Investigator: Paul Stolee A summary of the intent for this network is below. For more detailed information please visit : http://www.nce-rce.gc.ca/Competitions-Competitions/Current-EnVigueur/NCE-RCE-2012/Index_eng.asp

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RECIPE FILE This recipe is rich in Vitamin D and Calcium!

Turkey & Potato Casserole __________________________________________

Prep Time: 30 min; Total Time: 35 min; Serves: 6 Ingredients:

4 large potatoes, peeled & sliced 2 white onions, sliced 2 garlic cloves, finely chopped

3-4 cups cooked turkey chunks

6 tbsp butter Salt & pepper Pinch grated nutmeg All-purpose flour 250mL cream (15% or 18%) 500mL grated Emmenthal cheese

Directions: Preheat oven to 375 F (190C). Combine all of the ingredients listed above in a large casserole dish and heat for 30 minutes.

Nutritional Information Serving Size = 1 cup (250 mL) 553 calories; 35.6 g protein; 0.6ui vitamin D; 0.44g calcium

Check it out! We have updated our website to include a Participant Feedback and Resources tab!

inforehab.uwaterloo.ca

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Knowledge Exchange Workshop November 26, 2010

The Canadian Health Services Research Foundation describes knowledge exchange as “collaborative problem-solving between researchers and decision makers. Tremendous improvements in innovation and operational efficiency in healthcare systems can be found when knowledge is exchanged between normally separate groups of people. This results in a better understanding of each other's work, new partnerships, and the use of research-based evidence in policy- and decision-making. Knowledge exchange supports and improves evidence-based decision-making to help ensure the best possible decisions are made in running our healthcare system.” (www.chsrf.ca/knowledge_transfer/index_e.php) The purpose of this workshop was to bring together researchers and decision makers, as well as those with day-to-day experience in home care. The 30 participants at this workshop represented the following groups:

Rehabilitation Service Providers

Community Care Access Centre (CCAC) representatives

Quality improvement project leads

Policy makers

Researchers and Graduate students Informative presentations about research findings and current quality improvement initiatives were followed by lively discussions. These generated innovative ideas to:

Improve the systems of care for home care clients who would benefit from rehabilitation.

Enhance the way information is shared and used for policy development, as well as the assessment, treatment and evaluation of rehabilitation interventions.

Integrate the RAI into practice and decision-making.

Generate new knowledge through research initiatives.

Feedback from the workshop participants indicated that there is great interest in and a need for regular exchange of information about research, pilot projects and tools across the home care sector. This workshop bulletin provides an overview of key messages from the presentations and highlights of participant discussions.

InfoRehab Home Care Research Project Purpose: To enhance musculoskeletal (MSK) rehabilitation through more effective use of health information across the continuum of care. www.inforehab.uwaterloo.ca Aims:

Engage home care administrators and clinicians in improving the understanding and use of health information for rehabilitation clients. Use available health information to answer important questions regarding the role of rehabilitation in home care. This will be achieved through advanced statistical analyses of available health information, using a large existing database of comprehensive health information on over 300,000 home care clients.

The Knowledge Exchange Panel members played a key role in a consultation process that included regional consultations, a Delphi survey, and the November workshop. We would like to thank all of you for your contributions that gave us new insights into the home care environment, ideas for future projects and possibilities for new research initiatives. Katherine Berg Paul Stolee

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Future Research Questions What home care indicators, based on the RAI,

can be developed to improve care, measurement and reporting?

What are the barriers to information sharing and what strategies are most effective to overcome the barriers?

How can we learn more about the impact of rehabilitation on specific home care populations?

Can statistical analyses be used to inform best practice guidelines?

Will standardized guidelines for sharing health documents improve information exchange, care and outcomes?

What is the cost benefit of rehabilitation for home care clients?

How can we evaluate the effectiveness of RAI education and process improvements?

Would a different model of service delivery improve client outcomes by improving the way information is collected, shared and used?

Why does RAI trigger rehabilitation to facilitate improvement but less often to prevent decline?

What factors influence the difference in rehabilitation service provision across LHINs?

Project Ideas Strengthen relationships between CCAC and

Service Providers and improve processes using a management of change approach.

Offer knowledge exchange and dissemination opportunities so home care professionals are aware of initiatives, innovations, and research.

Provide RAI training to CCAC case managers and service providers to improve assessment, care planning and interpretation of outcomes.

Create a centralized repository of rehabilitation based research, information and tools.

Tackle privacy challenges related to information sharing. Enhance service provider knowledge of Health Information custodians.

Develop policy for rehabilitation clients based on analysis.

Broaden the Integrated Client Care Project.

Integrate/package rehabilitation with other services (e.g. Nursing and PSWs)

Implement a multi-disciplinary approach to rehabilitation.

Develop processes and policies supported by technology that would facilitate information flow across the continuum of care.

InfoRehab Research Exchange Systematic Literature Review concluded:

Home-based rehabilitation achieved equivalent or better functional status and quality of life outcomes than inpatient rehabilitation

Statistical analyses demonstrated:

Rehabilitation (PT/OT) provided through home care programs, can achieve functional benefits for clients with MSK disorders, and system benefits in terms of successful discharges from home care and reduced LTC admissions

Many older home care clients who could benefit from rehabilitation do not receive it (77% of clients in this study)

There is great variation across LHINs about the level of rehabilitation provided to home care clients

RAI data can provide evidence of impact otherwise lacking at a system level These results are particularly significant given that resources for home care rehabilitation are being reduced in Ontario Surveys of home care providers and administrators showed:

A supportive work environment characterized by collaboration, educational approach, IT support and access to tools promotes sharing of RAI-HC data and other health information.

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Selected Presentations at a Glance

Using and Sharing Health Information in Health Care Selena Santi Paul Stolee Stephanie Hinton The results indicate that there is consensus about what facilitates information exchange but there is less consensus about the barriers. How can we better understand barriers to information sharing? What specific strategies can be put in place to facilitate information sharing?

In a Delphi survey, 40 home care health care providers were asked about barriers and facilitators for the use of health information in home care settings. The aim was to use their responses to support recommendations and solutions for improved use and sharing of health information. Overview of findings:

Further research into individual and combined modes of communication is required.

Consistency was very important leverage existing tools to enable more effective information sharing and reduce duplication

Need to increase opportunities to engage in information sharing

Need supportive work environment

Create patient documentation that is made available to all service providers across settings

Items for inclusion: diagnoses, safety needs, hospitalization reports

Supports in place for design, implementation, training, and trouble-shooting of technology-based tools

Creating awareness of capacity and functions of the inter-RAI information and training sessions

Capacity building strategies based on stakeholder needs At the workshop, participants validated the survey results and added perspectives about privacy, timing of information received and information sharing between service providers.

Community Care Information Management – Integrated Assessment Record Andrea Tait Kelly-May Moreau The healthcare system faces an aging population and a significant rise in chronic illnesses. Technology is helping Community Care providers collaborate with primary care physicians, hospitals, and ambulatory programs to enable Ontario seniors to continue to live independently with support from the healthcare system.

Goals:

Working with clients and care providers within the circle of care to assess and plan services using:

Right care setting: at home, in supportive housing, or in long-term care homes

Right services including: needs-based support only, more intervention needed, clinical referral needed

Services that help keep clients well and engaged in their own care

Ongoing common assessments provide a framework for clients and health service providers to work together to make decisions regarding current and future care needs across the continuum of care

Challenge:

Clinical client data within a community is difficult to access and resides in separate information databases

Over 2,700 community care organizations perform assessments that cannot easily be shared between organizations or community sectors

Opportunity:

IAR provides a near real-time view of client assessment data, including care received

Health care providers can use IAR to identify service overlaps and gaps; and generate trend outcomes (on a client by client, population, or health service provider basis)

Enable informed decision making for clients and their families

Establish accountability for successful outcomes and service delivery

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Predicting functional outcomes for MSK patients receiving home care: Does rehabilitation make a difference? Paul Stolee What are the benefits of home-based rehabilitation for older persons with MSK disorders?

Systematic Literature Review

Home-based rehabilitation achieved equivalent or better functional or quality of life outcomes than inpatient rehabilitation

Statistical Analysis Using Multi-State Markov Models - What is the impact of OT/PT on home care clients with MSK disorders?

Patients who are functionally “independent” and receive rehab are 1.57 times more likely to remain at home following home care

Patients with some IADL impairment who receive rehab are 1.79 times more likely to be have a “good discharge” and 1.46 times more likely to become more functionally independent

Patients with both IADL and ADL impairment are 1.17 times more likely to improve their functional status, and 1.32 times more likely to have a “good discharge”

Rehabilitation (PT/OT) provided through home care programs, can achieve functional benefits for clients with MSK disorders, and system benefits in terms of successful discharges from home care and reduced LTC admissions

Why is this important?

Many home care clients who would benefit from rehabilitation don’t receive it.

Resources for rehabilitation in home care are being reduced.

Recognizing Heterogeneity in 150,253 Home Care Clients Who Used PT/OT Services Josh Armstrong Can we determine the different types of home care clients who use PT/OT services?

Overall Objective: To develop rehabilitation client profiles.

Identified 7 clusters of rehab clients with differing: o Ability to carry out ADLs and IADLs o Patterns of disease, gender, home living status, cognitive ability

Preliminary work looking into outcomes (1 year after assessment) demonstrates significant differences in outcomes for each of the clusters

Cluster analysis can be used as a tool to organize and identify patterns within the rich array of information provided by RAI assessment tools

Heterogeneity exists in the home care rehab population and this should be considered when planning and/or running statistical analyses

Due to limited resources, we need to improve our understanding of the client population in order to best help them in an effective and efficient manner

CCAC Rehab Services in Ontario: Findings from RAI and administrative data Jeff Poss OACCAC provided anonymized, linked data from January 2007 until September 2008 on RAI-HC assessments, admission discharge and services visits to look at rehabilitation service variation between CCAC s

Key Findings:

Of all newly referred home care clients receiving services, 44% received OT, PT, or a combination of both OT & PT; 27% received PT; 27% received OT; and 3% received Speech Language Pathology.

Of newly admitted rehab program home care clients (SRC 92), 89% received OT, PT, or a combination of both OT & PT; 61% received PT; 46% received OT; and 6% received Speech Language Pathology.

Of community assessed clients (long-stay, expected to be on service longer than 60 days), 34% received OT, PT, or a combination of both OT & PT; 19% received PT and 25% received OT and 2% received Speech Language Pathology.

According to a standard measure of need (the interRAI ADL Clinical Assessment Protocol) 50% of those people who could benefit or improve their ADL performance from OT and or PT received it. Only 26% of those people who could prevent decline in their ADL performance received OT and/or PT.

Great variation among LHINs in the likelihood of receiving OT and/or PT by home care clients.

Home care clients are more likely to receive rehab services early in their episode of care, compared to later in the episode.

There is not a strong correlation between clients who could benefit from rehab and clients who actually receive rehab services in home care.

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Integrated Client Care Project Stephanie Lockert The home and community care landscape is being redesigned to offer increased value for clients. Home care client service delivery is being organized around client care groupings, focusing on: – Specialization – Integration – Coordination, partnerships,

and alignment with other sectors

Vision:

Home and community care clients in Ontario are supported by a system that offers optimal client outcomes using a value-based model of care

To deliver improved value, new models of integrated care are being implemented to support people with complex clinical and psycho-social needs who require help on a prolonged basis to live successfully in the community

The transformation of home and community care will spread to re-engineer Ontario’s health care system to dramatically improve value for Ontarians

Implementation:

ICCP is based on a complex set of interventions (value-based home care delivery model comprised of client outcomes oriented reimbursement, specialised case management, coordinated assessment, and integrated care delivery) embedded into a model of integrated care delivery across all health sectors.

Four population groupings have been identified for the project: wound care, palliative care, frail seniors and medically fragile children. Groupings will be rolled out sequentially along with comprehensive impact assessments to better understand the impact and effectiveness of the care model.

Using and sharing information in Care Coordination: A population based approach Kathryn Wise A population based focus allows focus for integrated teams and sharing of information in different ways.

1. Teams should focus on low tech, concise, simple ways to share information 2. Scripting notes, standard outcome measures, common communication tools

are proven ways to improve quality of care and outcomes 3. Standardized tools such as the RAI lay a great foundation for this