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Community Step Up Program
Funded by MH LHIN in Partnership with Acclaim Health
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Community Step Up Program
A 6 week multi-disciplinary approach to rehab for frail seniors & older adults with complex medical conditions (including stroke patients) requiring PT, OT, SLP therapy services Patients MUST require 2 out of the 3 disciplines Must have restorative potential Must be medically stable enough to participate in a 6 week long program Prevent and reduce avoidable ED visits, hospital admissions and delay LTC placement Provide caregivers with education and coping strategies to make caring for their Loved One more efficient, easier and safer To provide appropriate navigation and seamless transition to other programs and services
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Program Framework
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Aligning with Stroke Rehab Best Practices
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Lifemark’s Client Service Excellence
Seamless Transition of Care Collaborative Approach to Goal Setting and Care Plan Education Transitional Planning Post Transition Assessment Seamless transition of care in and out of program Patient Centred Care – Client & Caregiver Dedicated team with strong knowledge base and experience Providing a safe and comfortable environment – transfer of trust Quality based procedures Continuous quality improvement
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Seamless Transition of Care into the Program
Working in collaboration for client centered care: 24 hour response Medical Documentation Collected Conduct AUA Screener Inclusion / Exclusion Referral Source Update Referral Joint Assessment with Appropriate Disciplines Client and Caregiver are Both Required Assessment Physician Sent Notification Medical Information sent to Interdisciplinary Team for Review Prior to Assessment Coordination of Documentation Addressing Barriers Transportation Incontinence Medication Fatigue requires a committed team approach and strong coordination of care across regions and networks, with pre-hospital, acute care, rehabilitation and community-based healthcare providers working together to ensure optimal outcomes for patients and their maintain optimal adaptation, outcomes, and quality of life f
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Goal Setting & Care Planning
Comprehensive Assessment with Client and Caregiver Attainable Goals Most Important to Client and Caregiver Educational Plan & List of Required Resources Continuous Re-Assessment Caregivers are given the opportunity to share their concerns Medical files transferred from referral source are reviewed prior to the assessment by all appropriate disciplines Patients and Caregivers are both required for the assessment and both are active contributors to the restorative program (needs assessments, goal setting, interventions and education) Interdisciplinary team work together with client and caregiver to confirm attainable goals and interventions Discharge planning is the focus from Day 1 Ongoing assessment of the physical, mental, emotional, and social needs of both the patient and caregiver Ongoing assessment of Caregiver capacity and potential risks of burnout Ongoing coordination of additional programs, services and supports – ADP, Home safety assessment, dysphagia, nutrition, hydration, continence, and pain, respite stay Ongoing education is provided to both the client and the care Ongoing communication with interdisciplinary team and caregiver
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Education Education Plan is developed, written and provided to both the client & caregiver Ongoing education is provided to both the client and the caregiver Educational topics may include: Self management skills for mobility Strategies for activities of daily living Symptom management Home Safety Medication compliance Available community resources and how to access them Exercise programs Aphasia Programs Dietician Peer/Caregiver Support Caregivers are given the opportunity to share their concerns Coordination of program, services – ADP, Home safety assessment, dysphagia, nutrition, hydration, continence, and pain, respite stay Education topics related to the community include: Self management skills for mobility, symptom management, medication compliance, and activities of daily living Types of services available in the community and how to access them Need for follow up with primary health care providers for ongoing monitoring
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Transitional Planning
Every transitional plan is unique Review transitional plans with client and caregiver Final coordination of support services and programs Education Review risk factors and possible complications How to re-access rehab if they have a set back Home exercises and resources Vocational Re-training Referrals sent Discharge assessment sent to Primary Care Client Care Coordinator’s contact is provided for post discharge inquiries Client Satisfaction Survey Final coordination of support services and program Primary Care Physician Stroke survivor groups, Peer survivor visiting programs, Meal provider agencies, Exercise and falls prevention program Community agencies City Recreational programs aphasia, nutrition, hydration, continence, and pain Education Review risk factors and possible complications How to re-access rehab if they have a set back Home exercises and resources Vocational Re-training Mental Health
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Post Transitional Assessment
Lifemark conducts 1 month & 3 month follow-up calls Touch point to reassess success of the program Review discharge recommendations, referrals and compliance Opportunity to address any new concerns or needs Opportunity to connect with additional Community resources Measuring post discharge ED and hospital admission visits Provide encouragement
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Questions
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