Inpatient Rehab/ Discharge Planning Practices Pre- and Results f TC LHIN Hspitals 1.0 BACKGROUND The Patient Access and Flw Cmmittee f the GTA Rehab Netwrk develped a new resurce, Discharge Planning Guidelines fr Inpatient Rehab during the fall 2008 and winter 2009. The new guidelines set ut guiding principles, standards and discharge readiness criteria fr inpatient high tlerance and lw tlerance rehab prgrams t prmte best practices in discharge planning and facilitate timely discharge frm inpatient rehab. In preparatin fr the disseminatin f the new guidelines in May 2009, clinical teams in the inpatient rehab setting were asked in April, 2009 t cmplete a brief survey t identify the gal setting and discharge planning prcesses that were in place. The survey results were used t prvide a baseline f discharge planning practices that were in place befre implementatin f the guidelines. In Nvember 2009, a secnd survey was sent t inpatient rehab clinical teams t determine if the Discharge Planning Guidelines fr Inpatient Rehab had been implemented and hw well rehab prgrams were meeting the principles and standards within the new guidelines. This reprt prvides a summary f the pre- and pst-implementatin survey results. 2.0 APPROACH AND PARTICIPANTS Inpatient high tlerance and lw tlerance rehab prgrams prvided by GTA Rehab Netwrk members were invited t participate in bth surveys. The surveys were emailed t key cntacts within rganizatins wh were asked t disseminate the survey t their inpatient clinical teams. Reminder emails were sent t ptimize the respnse rates fr each survey. Pre-implementatin Participants: In ttal, 27 prgrams frm within the TC LHIN bundary respnded spanning and inpatient rehab prgrams. The rganizatins represented by these prgrams were: Baycrest, Bridgepint Health, Prvidence Healthcare, Trnt East General Hspital, Trnt Grace Health Centre, Trnt Rehab and West Park Healthcare Centre,. implementatin Participants: In ttal, 19 prgrams frm within the TC LHIN bundary respnded t the survey, spanning High Tlerance Shrt Duratin () and Lw Tlerance Lng Duratin () inpatient rehab prgrams. The rganizatins represented by these prgrams were: Prvidence Healthcare, Trnt East General Hspital, Trnt Grace Health Centre, Trnt Rehab and West Park Healthcare Centre. Review f Guidelines: The majrity (84%) f prgrams (=83%; =86%) reprted that their clinical teams had reviewed the new guidelines. Baseline Discharge Practices Evaluatin Results / February 2010 Page 1 f 12
f Guidelines: While nly 42% f all prgrams (33% f prgrams; 57% f prgrams) have actually implemented the new guidelines, a further 37% f prgrams (42% f prgrams; 29% f prgrams) are ready t rll ut the new guidelines within their rganizatins. In additin, 4 prgrams within 1 rganizatin reprted that althugh they have nt yet implemented the guidelines, their current discharge practices are aligned with the new guidelines. 3.0 PRE- and POST- IMPLEMENTATION SURVEY RESULTS: The questins in bth surveys reflect the guiding principles and standards utlined in the Discharge Planning Guidelines fr Inpatient Rehab. The questins and respnses frm the pre- and pstimplementatin surveys are summarized belw. results are als available in graphic chart frm in the Appendix sectin. 3.1 DISCHARGE POLICY D yu have a discharge plicy? Pre- 74 (N=27) 71 (N=17) 80 (N=10) 95% (N=19) 92% (N=12) % (N=7) If n, are yu in the prcess f implementing a discharge plicy? (Prgrams withut a discharge plicy) (Prgrams withut a discharge plicy) (Prgrams withut a discharge plicy) Pre- 71 (N=7) 60 (N=5) (N=2) (N=1) (N=1) Nt applicable Cmments: Since the pre-implementatin survey was dne, there has been an increase in the prprtin f prgrams that have a written discharge plicy with almst all prgrams (92%) and all prgrams having a written plicy in place. 3.2 GUIDING PRINCIPLES: IDENTIFICATION OF PATIENT GOALS Are patient gals identified thrugh a cllabrative prcess between the treating health practitiner and the patient? Pre- (N=27) (N=17) (N=10) Baseline Discharge Practices Evaluatin Results / February 2010 Page 2 f 12
% (N=19) % (N=12) % (N=7) Des yur team have established mechanisms fr the develpment and cmmunicatin f gals and plans with each patient/family? Pre- 89 (N=27) 82 (N=17) (N=10) % (N=19) % (N=12) % (N=7) Are the patient s identified rehab gals dcumented in the patient s chart? Pre- (N=27) (N=17) (N=10) % (N=19) % (N=12) % (N=7) Cmments: All f the and prgrams met the guiding principles pertaining t the use f cllabrative prcesses t identify gals, established mechanisms t cmmunicate gals and clear dcumentatin f the patient s gals. Mst rganizatins indicated that gals are develped thrugh frmal and infrmal meetings between the patient/family and individual therapists r all team members in patient/family/team cnferences. A few prgrams reprted that they use a gal assessment dcument t summarize, track and review patient gals and in sme prgrams, a Gal r Care Crdinatr is assigned t meet with the patient/family t develp gals. The gal summary dcument is inserted int the patient chart fr weekly tracking and review by the care team. Team cnferences and patient care runds are als used t review the frmal gals n a regular basis. Other tls used t cmmunicate and track gals include patient cmmunicatin binders, cmmunicatin bards in the patient s rm and gal sheets. In sme prgrams, gals are discussed prir t admissin and ne MSK prgram reprted that preperative educatin classes are prvided fr patients underging elective prcedures t review the patients expectatins fr the prgram. Baseline Discharge Practices Evaluatin Results / February 2010 Page 3 f 12
3.3 EARLY IDENTIFICATION OF ESTIMATED DISCHARGE DATES AND DESTINATIONS Is an estimated date f discharge determined fllwing admissin? Pre- 96% (N=27) 94% (N=17) % (N=10) % (N=19) % (N=12) % (N=7) Is an estimated prvisinal discharge destinatin determined fllwing admissin? Pre- 85% (N=27) 82% (N=17) 90% (N=10) 89% (N=19) % (N=12) 71% (N=7) Is the estimated date f discharge determined within 7 days f admissin? Pre- 50% (N=26) 56% (N=16) 40% (N=10) 63% (N=19) 58% (N=7) 71% (N=7) Is the prvisinal discharge destinatin determined within 7 days f admissin? Pre- 81 (N=26) 81 (N=16) 80 (N=10) 47% (N=12) 42% (N=12) 57% (N=7) Cmments: All f the prgrams and all f the prgrams estimate a discharge date and almst all identify a prvisinal discharge destinatin. Hwever, this is nt always dne within the recmmended timeframe (i.e. within 7 days f admissin). rehab prgrams are better able t meet the timeframe fr estimating a discharge date with 71% f prgrams identifying an estimated date f discharge. In, nly 58% f prgrams estimated a discharge date within Baseline Discharge Practices Evaluatin Results / February 2010 Page 4 f 12
the benchmark. Perfrmance is prer fr estimating a prvisinal discharge destinatin within the recmmended timeframe acrss bth prgrams (42%) and prgrams (57%). Prgrams that did nt meet the timelines within this standard cmmented that it is difficult t accurately predict discharge dates and destinatins early n in the admissin fr cmplex patients. It shuld be nted, hwever, that the intent f this standard is t encurage early discussins arund pssible discharge dates and destinatins t supprt treatment planning rather than requiring % accuracy in the predictin f where and when patients will be discharged. 3.4 IDENTIFICATION OF BARRIERS TO DISCHARGE Are patients screened fr factrs that may delay discharge? Pre- 81% (N=26) 81% (N=16) 80% (N=10) 95% (N=19) % (N=12) 86% (N=7) D yu develp a plan f care t address the identified barriers t discharge? Pre- 85% (N=26) 88% (N=16) 80% (N=10) % (N=19) % (N=12) % (N=7) D yu hld patient/family team meetings fr patients wh are at risk f a delayed Pre- discharge? (N=26) (N=16) (N=10) % (N=19) % (N=12) % (N=7) Fr patients at risk f delayed discharge, during which week fllwing admissin is yur first patient/family team meeting held? (Benchmark: By 2 nd week f admissin) (Benchmark: Within 4-6 weeks f admissin) Pre- 60% met benchmark 44% met benchmark (N=16) 89% met benchmark Baseline Discharge Practices Evaluatin Results / February 2010 Page 5 f 12
(Benchmark: By 2 nd week f admissin) (Benchmark: Within 4-6 weeks f admissin) (N=25) (N=9) 77% (N=19) 58% (N=12) % (N=7) Is there a written plicy t address challenging discharge situatins? Pre- 64% (N=25) 53% (N=15) 80% (N=10) 68% (N=19) 67% (N=12) 71% (N=7) Are weekly team meetings held t prmte cnsistency in the treatment apprach, review patient s prgress and begin frmulatin f discharge plans? Pre- % (N=25) % (N=15) % (N=10) % (N=19) % (N=12) % (N=7) Cmments: Almst every prgram screens fr factrs that may delay discharge and all prgrams develp a plan f care t address discharge barriers and hld weekly team meetings fr patients at risk f a t supprt treatment planning and address ptential barriers t discharge. Imprvement is needed in the timing f the first patient/family team meeting acrss prgrams. In the preimplementatin survey, 44% f the prgrams met the benchmark fr (i.e. by the secnd week f admissin) and imprved slightly t 58% in the pst-implementatin survey. In cmparisn, almst all f the prgrams pre-implementatin (89%) and all prgrams pstimplementatin met their benchmark (i.e. within 4 t 6 weeks f admissin). The survey als asked if prgrams have a written plicy t address challenging discharge situatins. Althugh this is nt a requirement and a stated standard in the guidelines, nly 68% f the prgrams have a written plicy. Such a plicy, thrugh its develpment and implementatin, can help t prmte cnsistency and equitable respnses t cmplex discharge issues and shuld be encuraged acrss all prgrams. the 3.5 MEASUREMENT TOOLS/CRITERIA TO DETERMINE DISCHARGE READINESS Baseline Discharge Practices Evaluatin Results / February 2010 Page 6 f 12
Des yur team use any criteria r measurement tls t determine when a patient is ready fr discharge? Pre- 69% (N=26) 56% (N=16) 90% (N=10) 89% (N=19) % (N=12) 71% (N=7) Cmments: There has been an increase in the prprtin f prgrams that use measurement tls t determine if a patient is ready fr discharge -- frm 56% f prgrams pre-implementatin t % pst-implementatin. Hwever, there has been a decrease in the prprtin f prgrams that d s frm 90% pre-implementatin t 71% pst-implementatin. 3.6 BENEFITS AND CHALLENGES OF IMPLEMENTING THE GUIDELINES Have the Discharge Planning Guidelines fr Inpatient Rehab been helpful t yur clinical team? Pre- NA NA NA 1 % (N=10) % (N=6) % (N=4) Cmments: The prgrams that have implemented the guidelines reprt that the guidelines have been helpful in: Increasing clarity and cnsistency in the discharge planning prcess Facilitating team cmmunicatin arund discharge planning practices Validating and reinfrcing existing prcesses respndents prvided the fllwing cmments when asked t identify any challenges encuntered in implementing the new guidelines: In ne prgram, allied health fund it easier t embrace the new guidelines mre readily than nursing, wh were adapting t a number f ther changes within the rganizatin during the same perid. Sme teams have had n educatin abut the new guidelines. There are cmpeting pririties within ne rganizatin, delaying implementatin. 1 Only respnses frm prgrams that have implemented the new guidelines have been included in the calculatin. Baseline Discharge Practices Evaluatin Results / February 2010 Page 7 f 12
The lack f available and timely access t Lng Term Care (LTC) beds can delay discharge. Patients/families at times express reluctance when asked t revise their LTC chices t facilities with shrter wait lists. Occasinally, patients/families have difficulty accepting that the patient s prgress has reached a plateau and that the patient cannt g hme. 4.0 SUMMARY: 4.1 IDENTIFIED STRENGTHS IN DISCHARGE PLANNING PRACTICES The pre-implementatin survey results shwed that mst rehab prgrams had incrprated a number f discharge planning practices within their prgrams pertaining t the cmmunicatin f gals, estimating a prvisinal discharge date and destinatin, screening fr factrs that may delay discharge and develping a plan f care t address barriers t discharge. In general, each f these areas has imprved since implementatin f the guidelines with a higher prprtin f prgrams meeting these standards. In the pst-implementatin surveys, all prgrams reprted that they: Identify patient gals thrugh a cllabrative prcess with the patient/family Have established mechanisms fr the identificatin and cmmunicatin f gals and treatment plans Dcument the identified patient/family rehab gals in the chart Estimate a discharge destinatin fllwing admissin Develp a plan f care t address identified barriers t discharge Hld patient/family team meetings when there is a risk f a delayed discharge Hld weekly team meetings t prmte cnsistency in the treatment apprach, review the patient s prgress and begin frmulatin f discharge plans. 4.2 OPPORTUNITIES FOR IMPROVEMENT There are 3 brad areas in need f imprvement. These include: 1. f the Discharge Planning Guidelines fr Inpatient Rehab While the majrity f and prgrams have either implemented r are ready t implement the new guidelines (79%), all prgrams are encuraged t frmally implement the new guidelines int their discharge planning practices. 2. Frmal written plicies: There has been little imprvement in the prprtin f prgrams with a written plicy t manage challenging discharge situatins: In, 67% f prgrams have a written plicy in place. In, 71% f prgrams have a written plicy in place. The develpment and implementatin f written discharge plicies prmte clarity and cnsistency in the management f discharge issues. Baseline Discharge Practices Evaluatin Results / February 2010 Page 8 f 12
3. Early Discharge Planning: There is rm fr imprvement in meeting the benchmark fr the timing f when the discharge date and destinatin is estimated (i.e. within 7 days f admissin). Only 63% f prgrams pst-implementatin met the benchmark fr estimating a discharge date (=58%; = 71%). Only 47% f all prgrams (cmbined) in the pst-implementatin survey met the benchmark fr early identificatin f a prvisinal discharge destinatin ( 42%; 57%). There is als rm fr imprvement amng prgrams, fr meeting the benchmark fr the timing f the first patient/family team meeting fr patients wh are at risk f a delayed discharge (i.e. by the 2 nd week f admissin fr patients; within 4 t 6 weeks f admissin fr patients). Acrss prgrams, nly 58% f prgrams pst-implementatin met the benchmark. (All prgrams met the benchmark.) Initiating early discussins arund when and where patients will be discharged is key t effective discharge planning as it sets the stage fr wrking with patients/families t discuss expectatins fr rehabilitatin and identify realistic gals. 4. Use f Measurement Tls t Determine Discharge Readiness: While all prgrams in the pst-implementatin survey use sme kind f measurement tl t determine discharge readiness, fewer prgrams d s (71%). The use f measurement tls can help t track prgress, guide treatment and mnitr discharge readiness cnsistently. 5.0 CONCLUSION: Fllwing the implementatin f the Discharge Planning Guidelines fr Inpatient Rehab develped by the GTA Rehab Netwrk s Patient Access and Flw Cmmittee in 2009, the clinical teams prviding inpatient rehab have reprted that this new resurce has been helpful in prmting practive, clientcentered and cnsistent discharge planning practices acrss inpatient rehab prgrams. The guiding principles, standards and discharge readiness criteria fr inpatient high tlerance and lw tlerance rehab prgrams set ut in the new guidelines supprt increased clarity and cmmunicatin arund discharge planning prcesses, including gal-identificatin and care planning. The new resurce als enables the nging mnitring f discharge planning practices against the standards within the guidelines. While there are pprtunities fr imprvement, the results f the pre- and pstimplementatin surveys als clearly indicated that rehab prgrams have incrprated many effective discharge planning practices t facilitate timely discharge frm inpatient rehab. Baseline Discharge Practices Evaluatin Results / February 2010 Page 9 f 12
APPENDIX A: Aggregated Results fr and Inpatient Rehab Discharge Planning Guidelines fr Inpatient Rehab Results Pre- and & Results, TC LHIN Hspitals (Spring / Fall 2009) Have the guidelines been helpful t yur clinical team? 0 Des yur team use any criteria r measurement tls t determine when a patient is ready fr discharge? Are weekly team meetings held t prmte cnsistency in the treatment apprach, review the patient s prgress and begin frmulatin f discharge plans? Is there a written plicy t address challenging discharge situatins? 69 68 64 89 Is first patient/family team meeting held at benchmark? 60 74 D yu hld patient/family team meetings fr patients wh are at risk f a delayed discharge? D yu develp a plan f care t address the identified barriers t discharge? 80 Are patients screened fr factrs that may delay discharge? 81 95 Is the prvisinal discharge destinatin determined within 7 days f admissin? 47 81 Is the estimated date f discharge determined within 7 days f admissin? 50 63 Is an estimated prvisinal discharge destinatin determined fllwing admissin? 89 85 Is an estimated date f discharge determined fllwing admissin? 96 Are the patient s identified rehab gals dcumented in the patient s chart? Des yur team have established mechanisms fr the develpment and cmmunicatin f gals and plans with each patient/family? Are patient gals identified thrugh a cllabrative prcess between the treating health practitiner and the patient? If n, are yu in the prcess f implementing a discharge plicy? 71 89 D yu have a discharge plicy? 74 95 Has yur clinical team implemented the Guidelines? 0 42 Has yur clinical team reviewed the Guidelines? 0 84 0 20 40 60 80 120 & Pre- () & () Baseline Discharge Practices Evaluatin Results / February 2010 Page 10 f 12
APPENDIX B: Pre-implementatin Results fr and Inpatient Rehab Discharge Planning Guidelines fr Inpatient Rehab Pre-implementatin & Results, TC LHIN Hspitals (Spring 2009) Des yur team use any criteria r measurement tls t determine when a patient is ready fr discharge? 56 90 Are weekly team meetings held t prmte cnsistency in the treatment apprach, review the patient s prgress and begin frmulatin f discharge plans? Is there a written plicy t address challenging discharge situatins? 53 80 Is first patient/family team meeting held at benchmark? 44 89 D yu hld patient/family team meetings fr patients wh are at risk f a delayed discharge? D yu develp a plan f care t address the identified barriers t discharge? 88 85 Are patients screened fr factrs that may delay discharge? Is the prvisinal discharge destinatin determined within 7 days f admissin? 80 81 80 81 Is the estimated date f discharge determined within 7 days f admissin? 40 56 Is an estimated prvisinal discharge destinatin determined fllwing admissin? 82 90 Is an estimated date f discharge determined fllwing admissin? Are the patient s identified rehab gals dcumented in the patient s chart? 94 Des yur team have established mechanisms fr the develpment and cmmunicatin f gals and plans with each patient/family? Are patient gals identified thrugh a cllabrative prcess between the treating health practitiner and the patient? 82 If n, are yu in the prcess f implementing a discharge plicy? 60 D yu have a discharge plicy? 71 80 0 20 40 60 80 120 Pre-implmentatin () Pre-implmentatin () Baseline Discharge Practices Evaluatin Results / February 2010 Page 11 f 12
APPENDIX C: implementatin Results fr and Inpatient Rehab Discharge Planning Guidelines fr Inpatient Rehab & Results, TC LHIN Hspitals(Fall 2009) Have the guidelines been helpful t yur clinical team? Des yur team use any criteria r measurement tls t determine when a patient is ready fr discharge? Are weekly team meetings held t prmte cnsistency in the treatment apprach, review the patient s prgress and begin frmulatin f discharge plans? Is there a written plicy t address challenging discharge situatins? 71 67 71 Is first patient/family team meeting held at benchmark? D yu hld patient/family team meetings fr patients wh are at risk f a delayed discharge? D yu develp a plan f care t address the identified barriers t discharge? Are patients screened fr factrs that may delay discharge? 58 Is the prvisinal discharge destinatin determined within 7 days f admissin? 42 57 Is the estimated date f discharge determined within 7 days f admissin? 58 71 Is an estimated prvisinal discharge destinatin determined fllwing admissin? Is an estimated date f discharge determined fllwing admissin? Are the patient s identified rehab gals dcumented in the patient s chart? Des yur team have established mechanisms fr the develpment and cmmunicatin f gals and plans with each patient/family? Are patient gals identified thrugh a cllabrative prcess between the treating health practitiner and the patient? If n, are yu in the prcess f implementing a discharge plicy? 0 D yu have a discharge plicy? 92 Has yur clinical team implemented the Guidelines? 33 57 Has yur clinical team reviewed the Guidelines? 83 86 0 20 40 60 80 120 () () Baseline Discharge Practices Evaluatin Results / February 2010 Page 12 f 12