Calgary Foothills Medical Center Early Supported Discharge Program This is a summary of responses from our meeting with Darren Knox on Tuesday July 16th, 2013; Individuals attending this meeting were Donna Cheung, Esmé French, Stefan Pagliuso, and Sylvia Quant. Prior to the meeting, questions were gathered from OSS Rehab Coordinator and Community & LTC Coordinator Groups. Darren Knox is the Unit Manager for the Calgary Stroke Program & Acute Care Units 100/111 at Foothills Medical Centre (Aberta Health Services, Calgary). 1) Organization of stroke care in Calgary: a. Foothills Medical Centre (FMC) is the primary stroke centre that takes all treatable strokes. EMS bypass in effect. b. If a patient is not brought in by EMS and ends up at the nearest hospital, if appropriate, the hospital emergency dept will contact FMC team to determine whether the patient is appropriate for transfer to FMC. c. FMC created a central referral source for all of Calgary and created the Stroke Rehabilitation Coordinator position; the Stroke Rehabilitation Coordinator handles and overseas all stroke referrals. d. Calgary has a little over ~1600 acute strokes in the past year of which 80% are brought to FMC. 85% of these stroke patients are admitted to FMC stroke unit and 15% are admitted to a neurosciences unit at FMC. e. Inpatient rehab options: FMC s inpatient rehab program (Unit 58) or Vernon Fanning Centre (VFC). f. The outpatient rehab option is called Community Accessible Rehabilitation (CAR) g. FMC Inpatient rehab program: i. 15-bed stroke component ii. For medically complex patients who have vocational, driving, and neuropsychology, or more nursing needs iii. usually the patients are younger, are working or in school h. Vernon Fanning Centre (VFC): i. VFC is separate service from FMC ii. This program has 40 beds and is considered an active rehab service. iii. Patients are usually an older population with less medical complexities and less nursing needs iv. Patients do not have a need for vocational rehab or neuropsychology services. 2) History of ESD in Calgary a. The ESD program at FMC has been running for ~ 4 years. b. A 1-yr pilot occurred in 2009. c. After this pilot, the hospital started an Accreditation process from this learning, they formed an Access to Rehab Group this group looked at access for stroke patients within Calgary. Their findings showed: disjointed services involving multiple 1 P a g e
providers/services, delay in care or access to rehab services, increased LOS, and gap in community services. d. Based on Access to Rehab Group findings, this resulted in the following: i. A centralized referral process using 1 referral form for all services ii. The creation of a new position termed: Stroke Rehabilitation Coordinator : she/he would receive all referrals, review charts, meet with teams/pts/families and allocate patients to the most important programs/service. iii. Revisions to their ESD program revised FTEs and revised admission priorities, iv. The initiation of a 2 nd 1-yr pilot, which resulted in secured funding to maintain the ESD program. 3) Funding a. Most stroke services happen at FMC. As such, provincial money for stroke has been allocated to FMC, which funds the ESD program. b. Of the 1.22 million budget, $100,000 has been allocated towards travel and equipment expenses. 4) ESD admission criteria a. Patients need to be appropriate and ready for rehab, with rehab goals and potential b. Teams need to feel that the patient is safe to bypass inpatient stay c. These patients usually have a projected AlphaFIM score of 80 and above (for exceptions, see below) 5) ESD vs Outpatients a. Due to the long wait time to access outpatient services, the patients who would benefit from outpatients are also referred to ESD; from the ESD program, these patients would then be referred to outpatient services as needed/appropriate. b. Some patients also access outpatients right away. c. For those who need neuropsychology, a vocational consultant, or a driving assessment, the team tries to get these patients into outpatients as soon as possible; neuropsychology, vocational services, or driving assessments are not offered within the ESD program. 6) Referral decisions for ESD are based on 3 priorities: a. Priority 1: those who are from acute care, need inpatient rehab, but could go home first; these patients are usually seen within 24 hours post discharge from acute care. b. Priority 2: those who are from acute care but could be discharged home sooner. c. Priority 3: those from inpatient rehab who could get home sooner. d. In other words, acute care gets priority over inpatient rehab patients in doing so, they have had a significant reduction in LOS in acute care and rehab. 7) Use of AlphaFIM Instrument: a. AlphaFIM Instrument is being used on every patient within 72 hours in acute care. AlphaFIM triaging at FMC is used as a guideline in addition to NIH and other measures. b. For inpatient stroke rehab, there is a preference to refer patients with an AlphaFIM score of 40-80; they may consider a patient <40 if this patient is <55 years of age. c. The ESD program has seen a few patients with an AlphaFIM score of < 80. 2 P a g e
d. Most of the patients in the ESD program have a mild severity (they use AlphaFIM or whatever is available to them to determine stroke severity). e. In addition to stroke severity, during discharge planning, the team uses the AusTOMS to consider the level of impairment. For instance, a patient may have the same stroke severity but have different levels of impairment (speech vs arm impairment) 8) ESD Rehab Intensity: a. Currently, patients are seen each business day, M-F, excluding stat holidays. b. Therapy Assistants will see the patient every business day. c. For the rest of the team (allied health and nursing), patients are seen 2-4 times per wk depending on the patients needs d. Most moderately disabled patients are seen 3 x per wk on average by various disciplines. e. Most mildly disabled patients are seen 2 x per wk on average by various disciplines. f. Over 1 ½ hrs of therapy are provided on average per day. Their target is 2 hrs per day (as opposed to 3 hours/day)- Rationale for the 2-hour target is based on patients high fatigue levels while at home; patients are doing more in the community and get fatigued easily at the time of the appointment; patients also have other activities that may limit their therapy time (e.g., banking, other appts, visiting grandchildren, etc.). 9) ESD Initial Assessment/team coordination: a. Intake assessments are ideally conducted while the patients are in hospital; however, if this is not the case, these assessments would occur within 24 hours post discharge b. Any therapist on the ESD team could do the intake assessment. Therapy Assistant is also present on the 1 st day so that treatment is initiated right away. c. Other team members will be consulted as needed. d. A case manager (who is not the intake coordinator) would be assigned for each patient. The case manager is the person who is most involved with the client (could be the therapist). 10) ESD team and its office location a. The ESD team consists of all new hires. b. Office is located in a separate and centralized location in downtown Calgary; this location reduces commute times for team members City is divided into quadrants and therapists see patients within these quadrants c. Any congregate visits? i. Most sessions are 1:1 or 2:1 (co-treatments have been done for example: OT and S-LP working together on a cognitive assessment; Physio and Rec; OT and PT, etc.) ii. Group sessions are not the norm. They have had SLP group sessions. However, there has not been too much success due to transportation issues. d. A lot of team members do not go to the downtown office daily. Only ~ 1 time per wk for team rounds and education. e. They use smartphones as much as possible (communicate via text, email, telephone call). They minimize face time and travel time. 3 P a g e
f. RN and SW have been doing more telephone sessions with their clients as appropriate to reduce the drive time. g. Team members spend on average 1 ½ hours of driving per day. 11) Impact of ESD on other community services or programs? a. Impact on CAR (FMC s outpatient service): waitlist is shorter than before; they probably see ½ of the # of stroke patients than what they used to see; ESD refers 1/3 to CAR after ESD- these patients usually are referred for ongoing OT and S-LP services (e.g., for higher level cognitive/language issues). There were no changes to staffing in CAR as CAR is not a stroke-specific service (i.e., CAR also sees ortho,medically complex patients, brain injury, MS, etc.) b. Impact on other community groups: ESD has been able to promote groups such as the Stroke Recovery Association. Better recruitment has been noted. Living with Stroke enrolment has also probably increased due to ESD. c. As ESD has been seeing most patients who would not normally be receiving home care, home care services have not been greatly affected. 12) ESD Performance Measures a. Some measures may have changed since 2011 data. b. After the 2011 report and 2012 Stroke Congress presentation, they will not be producing any future formal reports. Instead, once every quarter, they will be meeting with organizations to share/report data across the continuum of care. c. Darren shared the following current data: i. For acute care, 98% get ESD treatment within 24 hours; 2% get this within 48 hours. ii. For tertiary inpatient rehab, 100% get ESD treatment within 3 working days. iii. Average LOS: 38 calendar days, roughly 5 wks (they now go by calendar days as opposed to service days) iv. Number of referrals per month approx 12 referrals per month (numbers were down last year and the ESD team is currently looking into why this is the case). v. For the pilot, FIM was used to compare with their inpatient rehab program. However, due to its ceiling effect, they have decided to not collect the FIM. vi. AusTOMS: no current results as of yet. All patients had improvement on this measure but specific data not available. vii. 100% of ESD clients would recommend service to a friend/family member. viii. 95% responded positively to the ESD program (Of the 5%, some suggested that there should be more written education materials) - ESD uses technology with minimal use of brochures, etc. d. Currently, the ESD team is not as focused on reporting COPM and AusTOMS. Rather, the focus is on cycle times and system impact. e. Although therapists will conduct various assessments, the ESD team has been selective re: which measures to use/track/report. 4 P a g e
13) Workload tracking a. The ESD team has eliminated the time for entering workload stats. They have created a bridge between their scheduling software and their workload measurement reporting system. Instead of spending individual time tracking/inputing data, they now spend 2 minutes reviewing their schedules for accuracy. 14) Next steps a. The ESD team is looking into how to further imbed themselves into the stroke continuum care in Calgary. i. For example, last year, when staffing was low in acute care and there were low referrals for the ESD team, the ESD team went into acute care to assess and treat pts at FMC. This experience helped stroke care at FMC when it was most needed, it strengthened relationships between FMC staff and the ESD team, and it increased knowledge and education re: each other s care environments. ii. A continuum care advisory committee has been set up this committee is looking at how the ESD team can be used when there are changes in the system. (i.e., when there is a large influx of stroke patients in a particular area of the continuum, they are looking into how to mobilize their resources to better meet the current demands, etc.). They are also looking into how to expose healthcare providers from other teams to the ESD environment. iii. More discussions will be happening on what this would look like for the futurefor example, will ESD become a philosophy of care for all programs, etc. b. They are looking into treating more patients with a higher intensity. They are investigating why the ESD program had low numbers last year. They are continually striving towards a rehab intensity of up to 2 hours/day. c. Additionally, with respect to stroke prevention, they are looking into how ESD nursing services can be meshed with SPC services. They found that the nursing role could assist with more timely help with meds, risk factors, education on prevention etc. In other words, people have been able to get timely access to nursing care and education before their 3 month Stroke Prevention Clinic (SPC) follow-up. Addendum: On July 26, 2013, Darren Knox provided further information on their ESD program at FMC: 1) What are your current FTEs for your ESD team? Response: Current FTEs for their ESD team are the following: i. 1 x 1.0 FTE Clinical Leader (also practices as an OT) ii. 3 x 0.5 FTE OT iii. 2 x 0.8 PT iv. 1 x 0.8 Recreational Therapist v. 1 x 0.5 RN vi. 1 x 0.8 SW vii. 2 x 0.5 S-LP 5 P a g e
viii. 4 x 1.0 Therapy Assistants ix. 1 x 1.0 Admin Clerk 2) For data that were mentioned in the interview (e.g. % starting ESD treatment within 2 days, etc.), were these based on 2012/13 data? Response: Yes, from Jan 1, 2013 to present. 3) How many Stroke Rehab Coordinators do you currently have? Response: Currently piloting positions: 1 x 0.6 FTE and 1 x 0.3 FTE; however, a current request has been made to fund 2 positions: 2 x 0.6 FTE. 4) Does your program provide ESD to patients within a certain km radius of FMC? Response: No, we provide ESD service to anyone within the Calgary city limits. 6 P a g e