1. Rapid Rehabilitation & Reablement (R&R) for Seniors
Wandlyn Richards, BSc, RRT, MBA
NB Extra-Mural Program: Fredericton and Upper River Valley Area
Clinical Care Management Coordinator

2. Intent/goal/aim Rapid Rehabilitation and Reablement (R&R) for seniors
identified under the provincial Home First strategy
aligns with Horizon Strategic Plan, 2015
aligns with seniors values and their desire to remain in their homes and live independently with the appropriate supports
enhancement to services provided by the Extra-Mural Program (EMP) and Social Development (SD)

3. Philosophy is based on in-home and community based care that is enhanced, rapid in nature, supports self-management and promotes independence
When seniors have timely access to community-based rehabilitation services:
they can recover faster after illness or injury
shorten a hospital stay
restore/optimize their independence
prevent and/or delay unnecessary and more costly forms of care and remain home

4. Problem/Issue
“Seniors have stated that they want to stay at home and in their communities for as long as possible. Evidence shows that community-based care is often the most appropriate and cost effective means of providing care.” Home First, 2015
With current challenges around hospital congestion, patient flow, and ER wait times; projects like R&R contribute to an overall system transformation by moving seniors to the community and avoiding lengthy hospital stays

5. Problem/Issue
Timely and appropriate interventions to assist seniors with remaining in their homes and avoiding unnecessary hospital admissions and residential placements, will help to achieve significant cost avoidance and better patient outcomes
Up until this initiative, there were gaps in providing community-based services to this senior population: barriers that prevented timely access to EMP professionals and limited home support hours

6. Measurement
In July 2015, a nine month “Proof of Concept” for R&R was implemented in Zone 3
Evaluation framework had two components:
Patient Level:
# screened, # enrolled, # completed , patient demographics, most responsible diagnoses, # visits by EMP disciplines, # HS hours, duration of R&R and outcome for patient
validated measures of mobility and function were completed with each patient pre and post R&R service
Patient/family surveys provided information around patient engagement and education, patient satisfaction and patient/family comments
System Level:
Length of stay in hospital, rate of admissions to hospital, rate of visits to ED,
patient flow in hospital, length of stay of ALC patients in hospital

7. Results 131 seniors were enrolled average age 80.3 years (72% female)
77.8% entered from hospital
most common diagnosis was fracture (45%) - followed by falls, COPD, and CHF
82% successfully completed care as planned
overall patient satisfaction was high and over 84% felt that their care needs were better met with R&R compared to if they had remained in hospital
“The R&R service for seniors was a great benefit to me and my family. Because of R&R I believe I regained my activities faster at home than I would have in another facility.”

8. Functional Outcomes Clinical Measures Frailty (Clinical Frailty Scale)
Prior to R&R
(Avg)
After R&R
p-value
Statistically
Significant
Improvement?
Frailty
(Clinical Frailty Scale)
5.31
4.50
<0.0001
YES
Care Giver Strain
(Zarit Burden Interview)
21.21
18.65
0.063 NO
Mobility
(HABAM)
17.28
20.82
Activities of Daily Living
(Katz Index)
3.58
5.21
Instrumental Activities of Daily Living
(Lawton Scale)
3.54
4.58

9. Intervention/Actions
Rehab & Reablement targets seniors 65 years and older
Have health needs expected to improve with short-term intensive care and interventions to restore functional independence
Identified in hospital and no longer require acute medical care with a diagnosis of:
Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Diabetes, Mild-Mod Stroke or TIA, Fracture (in hospital receiving rehab, convalescence & general strengthening interventions) and fall/musculoskeletal injuries
Identified at home and at risk of hospital admission with one of the above diagnoses or have been diagnosed with mild-mod Dementia

10. R&R Service Approach: Enhanced services provided for up to 9 weeks
Rehabilitation (up to 3 weeks) - at home or transitional placement in a designated Special Care Home (SCH) and,
Reablement (up to 6 weeks) at home
EMP health care provider assessment/admission within 24 hours of discharge (not wait-listed)
Home support hours put in place up to 6 hours /day without a financial needs assessment or system delay (within 24 hours)

11. Impact/Outcomes
“My Health Plan” tool was implemented to identify the patient’s goals/focus of care in their own words and to support care planning. It is kept in the patient’s home and is used as a communication tool for all providers to coordinate effort while encouraging the patient/family to actively participate
Developed guidelines for conducting patient/family conferences
“Blue Folder” left in the patient’s home as a communication hub
Improved response time for initial EMP assessments (within 24 hours) and increased frequency and intensity of interventions

12. Impact/Outcomes
Development of “Integrated Care Pathways” - best practices
Enhanced EMP service provision with 7 day coverage to include Physiotherapists, Occupational Therapists, and Respiratory Therapists
Home support initiated without a financial needs assessment and delay
Rehabilitation Assistants added to the EMP health care team
Improved care coordination and communication between health providers

13. Lessons Learned/Challenges
Required significant integration and collaboration between internal and external partners
Required a significant culture shift of hospital care teams, EMP providers and physicians to provide a more seamless, integrated service as partners
Requires strong communication and consistent messaging

14. Lessons Learned/Challenges
Risk avoidance that hospital care teams had to overcome, allowing EMP to “replace” or “carry- on” hospital level rehabilitation care at home
Personal care aides philosophy change from “doing for” to “doing with” the patient to promote independence
Required proactive identification of potential patients daily within hospital care units to facilitate early supported discharges

15. Rapid Rehab & Reablement moving forward….
Proof of concept demonstrated success and currently being rolled out in Zone 1A and 1B, and soon to be implemented in Zones 2 and 6 (fiscal year 2016/17)