Life’s transitions and changes – especially those experienced following an illness or surgery are the inspiration behind Providence Healthcare’s innovative Pre-Rehab Care Service. This unique service within Providence Hospital’s Complex Continuing Care Program bridges a gap for patients who no longer require acute care, but are too weak or dependent to manage the more rigorous demands of an active rehabilitation program.
Launched a year and a half ago, the Pre-Rehab Care service helps people recover and achieve the endurance they need for rehab, while maintaining a pace that is comfortable and sustainable for them. The service has also contributed to an increase in patient and family satisfaction levels.
The need for the service was identified during an external scan conducted as part of Providence Healthcare’s strategic planning process. The scan identified a gap in care for patients needing many different types of rehabilitation within the Toronto health care system. Although these patients were eventual candidates for active rehab, they were not yet ready to withstand the demands of the program. Without an appropriate service to help them, these patients often remained in acute care longer than necessary, contributing to extended lengths of stay and somewhat delaying progress in their overall recovery.
“Some patients who are discharged from acute care hospitals after injury, illness or surgery, and referred for rehabilitation are simply not ready, either physically or psychologically for the demands of rehab,” explains Social Worker Elaine Rolfe, who notes this can be especially true of older patients, many of whom are still frail when they are discharged.
The solution provided through the Pre-Rehab Care Service is a modified rehabilitation program provided up to three times a week. With an average length of stay of 56 days, it’s a flexible stepping stone to active rehab for patients who have had strokes, lower limb amputations, hip or knee replacements or fractures. Once ready for active rehab, patients participate in extensive therapy up to five times per week.
The time from acute care referral to admission at Providence Hospital takes 10 days on average. Upon admission, the first step is a thorough assessment of the individual’s physical, emotional and social needs. Working together, the inter-professional team focuses on building the physical strength and skills the person will need to enter an active rehab program. The inter-professional team includes nurses, physicians, occupational therapists, physiotherapists, a social worker, a dietician, a pharmacist and therapeutic recreationist, to mention a few.
Each team member contributes his or her own particular expertise. Constant communication and sharing of information among the care team members are vital contributors to the patients’ overall success.
For instance, Janet Gleason, the Professional Practice Leader – Occupational Therapy, will consult on seating and mobility issues and assists patients to achieve the necessary level of function and physical tolerance.
“Social work, on the other hand, goes over the criteria the patient needs to meet and we all work together towards achieving them,” says Rolfe, who adds that many of the patients have been able to return home directly following active rehab and continue their rehab on an outpatient basis in the community.
Less than two years old, the Pre-Rehab Care Service has already proven itself. The implications for best practice are reduced lengths of care within acute care, and an environment that integrates rehab at every level to support recovery. Patient and family satisfaction has increased, and the model demonstrates a new focus that can be applied to complex continuing care.
In addition, the service demonstrates the value of developing ongoing partnerships with acute care for a seamless continuum of care across the system overall.
The Pre-Rehab Care Service is one component of Providence Hospital’s extensive Rehabilitation and Complex Continuing Care programs and services, which also include specialized stroke rehab, specialized geriatric rehab, orthopaedic rehab, amputee rehab, palliative care and transitional care for patients awaiting long-term care placement.