1. Improving The ABI Transition Experience Hospital to Home/Community Elly Nadorp, MSW.,RSW enadorp@toh.on.ca

3. 58 bed speciality centre (12-14 inpatient ABI beds) provides comprehensive in- and outpatient rehab services to residents of Ottawa and Champlain Region, Ontario, Canada ABI Care stream- regional program providing a model of service delivery encompassing a cognitive behavioural framework. Includes inpatient, day hospital, residential and outreach services. The Ottawa Hospital Rehab Centre ABI Care Stream

4. ABI Patient Journey 4 Day Hospital

5. Relevance of the Transition Project Through self assessment of Accreditation Canada ( 2009-standard 31) “ How does the team make sure that clients and families are prepared for the end of services” was not addressed adequately The NRC Picker Client Perspective of Rehabilitation Services Questionnaire indicated lower then expected patient satisfaction ratings for “continuity and transition”

6. ABI Client Perspectives of Rehabilitation Services Dimension of Care: Continuity & Transition (Jan-Dec 2009 ) * Positive scores for this question reflect the percent of “Strongly Disagree” and “Disagree” ratings combined. Referrals to Home care Expected progress at home Medication side effects

7. To improve the tools and processes employed to prepare and support patients at discharge from inpatient rehabilitation Purpose of the Transition Project

8. Action Plan A coordinated strategy was needed to improve the transition experience from acute inpatient rehab to home and community A Project Team was established consisting of representatives of different disciplines and from research centre Input from consumers was paramount

9. Process A quality improvement methodology and tools were employed to identify the problem and develop test cycles to develop and test solutions. Project Team obtained data from patients and family members using structured phone interviews, questionnaires and focus groups to gain insight into their information needs.

10. Process continued Review of Best Practice Guidelines for general information and specific discharge needs for ABI patients Staff Focus Group

11. Consolidated Findings and Key Information Gaps Handover to Family Physician/Other Providers What to expect at home (Guide) How/when to contact the hospital (Guide) List of community resources (Guide )

12. Handover to Family Doctor /Other Providers Physiatrist has discharge summary written at time of discharge from inpatient rehab Discharge summary send to family doctor electronically or fax. Copy of discharge summary given to patient on day of discharge

13. Creation of the Transition Guides 2 comprehensive documents were created for both the patients and the caregivers by project team Level of language and visual layout were important variables in the development to facilitate comprehension Each document was reviewed by clinical staff, patients and caregivers, involving a series of edits The guides were pilot tested with 30 patients

14. Content of the Guide Contact information to hospital and community resources General information about topics important to living with an ABI Space for patient specific information, which could include : follow up appointments, test results and recommended cognitive strategies Process and information to allow patients easier access to providers

15. Implementation of Transition Guides Patient guide is provided to the patient shortly after admission to inpatient unit by the triage/admission nurse Patient manual review is incorporated in individual and group therapy Caregiver manual is provided to and reviewed with the caregiver by the social worker.

17. Evaluation of Transition Guides Feedback questionnaires will be sent in summer of 2013 to patients and caregivers for feedback regarding the usefulness of the Transition Guides

18. Conclusion Quantitative and qualitative patient and family feedback was sought, and incorporated with evidence based recommendations to produce an improved product and consistent process for our ABI patients and families The type of methodology, within a quality improvement framework, is transferable to many other projects

19. Acknowledgements and Contact Information ABI Project team Patients, Caregivers, Staff The Ottawa Hospital Rehabilitation Research Centre Elly Nadorp, MSW.,RSW. enadorp@toh.on.ca Tel: 613-737-7350, ext: 75593