1. Reducing Wait Times to Outpatient Rehab for Stroke Patients
2017

2. About Outpatient Neuro Rehab Services
Interdisciplinary Outpatient Rehabilitation Team
Single and Multi-Service
Eligibility criteria
Social Worker (SW)
Speech-Language Pathologist (SLP)
Physiotherapist (PT)
Occupational Therapist (OT)
A recent stroke within the past 9 months
An acquired brain injury (e.g. aneurysm) within the past 12 months
A neurological condition (i.e. multiple sclerosis, degenerative conditions
Criteria:
Be over 18 years old
Be medically stable
Have shown recent progress and have clear rehab goals
Be able to tolerate at least a 3 hour program plus transportation time (less if only one service is required)
Commit to attend regular sessions and complete recommended home activities and/or exercises
Be under the care of a family physician
Live within Trillium Health Partners’ service area

3. Service in Trillium Health Partners’ Outpatient Neuro Rehab Program was not meeting the Canadian Stroke Best Practice Recommendation of patients accessing outpatient rehabilitation services 48 hours post-discharge from acute care and 72 hours post-discharge from inpatient rehab. A baseline snapshot collected manually from Jan to June 2016 (complex cases only) showed an average wait time of 58 days.
This has a negative impact on patient flow through the health system, stroke patients’ quality of life and the overall patient experience.
It also negatively impacts outpatient staff morale due to an increase in administrative tasks required to manage the waitlist, and their perception of not providing optimal care for patients.
The problem
Canadian Stroke best practice guidelines:
Community/outpatient rehabilitation should be initiated 48 hours post-discharge from acute care and 72 hours post-discharge from inpatient rehab
Wait times are consistently much higher than that.
Average wait time in 2016 at 58 days
Variability between disciplines

4. IDEAS advanced learning program
IDEAS (Improving & Driving Excellence Across Sectors)
IDEAS advanced learning program
Program used as platform to drive quality improvement work forward related to the access issues stroke patients were experiencing.
Training program by Health Quality Ontario, focused on quality improvement
Advanced Learning Program is intended for health care professionals (clinical or management) who are looking to lead quality improvement projects
5-month program
Classroom component and applied component: you need to have a project in order to apply
You get a quality advisor to help you with your project
Currently accepting applications for Cohort 16 (starts in September, applications due May 28)

5. Janine Theben, West GTA Stroke Network - Rehab Coordinator
Pamela Rahn, SLP, Outpatient Neuro Rehab Services, Trillium Health Partners
Holly Sloan, SLP, Inpatient Stroke Unit, Trillium Health
Stacey Williams, West GTA Stroke Network - Stroke Navigator
The core project team

6. Overall Project Aim: We hoped to decrease the amount of time stroke patients wait for the Outpatient Neuro Rehab program by 50% by December 2017
IDEAS AIM 1: To reduce the maximum length of stay in the outpatient program from 12 weeks to 8 weeks by May 2017
IDEAS AIM 2: To reduce the amount of time therapists spend on administrative tasks related to waitlist management by 30% (compared to baseline) by June 2017
The goals
How did we come up with these goals? See next slide.

7. Driver diagram
In-depth consultation with staff at the very beginning of project- we actually initially used a fishbone diagram or ‘brainstorming’ exercise to allow the team to identify what they felt were the barriers to improving access to the program which then generated several change ideas.
Goal was to identify what the factors are that affect wait time
Evaluate how much of an impact each factor has
Which factor is one that we can actually change?

8. Goal: less time spent on waitlist management and booking
Increase Supply

9. Reduced maximum length of stay from 12 weeks to 8 weeks
But: referral numbers also continue to increase
Decrease demand
2015
2016
2017
Increase in past 2 years OT
288
311
373
30% PT
219
242
230 5%
SLP 78
102
117
50% SW 31 46 47
We also tracked percentage of patients with a LOS 10 weeks or less to check on how well clinicians were able to maintain this target with their clients. This has remained fairly stable hovering around 60 percent. (so 60 of patients have LOS 10 weeks or less, 40 percent are over).

10. Team and clinicians were worried about possible negative effects, especially of shortened length of stay
Tracked ability of clinicians to set meaningful and achievable goals for an 8-week LOS (clinician rating and comments collected)
Tracked patient satisfaction with the program overall and with progress towards their goals
Balancing measures
Add into the notes some comment on these two things:
i.e. Overall clinicians felt they could set meaningful and achievable goals with clients within the 8 week timeframe – with some exceptions to the rule
Patient satisfaction was maintained
Balancing Measures:
Patient Satisfaction Surveys: To ensure patient satisfaction remained excellent. 100% of patients indicated they would recommend this program to a friend pre- and post change. 78% indicated wait time to first appointment was acceptable post change (65% at baseline).
Goal Feasibility Rating Scale: To ensure patient goals were still being met despite reduced LOS from 12 weeks to 8 weeks. Clinicians indicated they were “confident or very confident” they could set goals that could be met within the 8 week LOS and that clients actually met these goals within the 8 week LOS. Clinician comments were tracked when goals were not met and included factors related to patient (fatigue, self discharge, acute medical issues, missed appointments) and transportation (unable to attend more than once per week) rather than shorter LOS.

11. Wait time per month per discipline
We started tracking using run charts as our ‘baseline’ snapshot was a lumped together average from both services over a 6 months period (the 58 days) and using this format allows us to go back and take information to the team when we see ‘blips’ to find out what was happening. For example in Nov, OT had a few very complex patients who were picked up alter due to various explainable reasons and SLP was away on vacation, hence the ‘blip’ you see on the chart.
Comment on TOTAL AVeRAGE WAIT TIME currently (combined) (so you can just say what is it now, we will need to calculate this).

12. Month-to-month variability was greater than we expected – will need to measure results over a long term
If possible track and record any factors that can influence your result
Involve as much of he frontline team as you can in making the initial plan
Communicate frequently with all stakeholders
Lessons learned
Comment on the fact that we never thought about the effect of increasing referral volumes. Because the referral volumes keep increasing, even though we changed the LOS from 12 weeks to 8 weeks, this change idea still may not bring about a real reduction in the overall wait time, but rather will help to ‘maintain’ the current wait time. Moving forward we may need to go back to the drivers diagram to consider what else can be done to align the ‘demand for the service with the ‘supply’.
Also to keep in mind that for many patients during their ‘wait time, to OP service they are actually receiving care from the MH LHIN CCAC Stroke Rehab clinicians, but because our two data systems are not connected we can not track these patients true ‘wait’ from end of that service to start of OP service.