Rehabilitative Care Alliance Assess & Restore/Frail Senior Medically Complex Task & Advisory Groups DRAFT Terms of Reference Background Ontario’s 14 LHIN CEOs established the Rehabilitative Care Alliance (RCA) in April 2013 to bring a true provincial lens to improving patient experiences and clinical outcomes in rehabilitative care. Under the leadership of the RCA Secretariat (provided by the GTA Rehab Network), the group brought together representatives from all LHINs, the Ministry of Health and Long-Term Care (MOHLTC), health service providers from hospital and community sectors, and other clinical experts, as well as patients and caregivers to develop collaborative solutions to advance a philosophy of rehabilitative care in Ontario. The RCA completed its first mandate in March 2015 and a second two-year mandate has been approved to begin on April 1, 2015. During its first mandate (April 2013 – March 2015), the RCA focused on 5 priority areas: Definitions of Rehabilitative Levels of Care; Capacity Planning and System Evaluation; Frail Seniors / Medically Complex; Outpatient / Ambulatory; and Planning Considerations for Re-Classification of CCC/Rehab Beds. (For a copy of the full report, please visit www.rehabcarealliance.ca.) Every effort was made to align priority activities with provincial initiatives and to contribute to the rehabilitation recommendations outlined in the 2013 Annual Report of the Auditor General of Ontario. Objectives In December 2012, Living Longer, Living Well. Highlights and Key Recommendations from the Report Submitted to the Minister of Health and Long-Term Care and the Minister Responsible for Seniors on recommendations to inform a Seniors Strategy for Ontario was released. Authored by Dr. Samir K. Sinha, Provincial Lead for Ontario’s Seniors Strategy, the report includes a description of an ‘Assess and Restore Framework to Support Aging in Place’ and recommendations related to ‘Enhanced Screening and Detection of Functional Loss’ and ‘Enhanced Assess and Restore Services Provision’ intended to support the development of the Assess and Restore Framework. In response to the framework, the MOHLTC developed an Assess and Restore Guideline in collaboration with LHINs, HSPs, and clinical experts from across the province. The Guideline, published in October 2014, outlines expectations and defines the roles and responsibilities of LHINs, HSPs, and care providers in delivering Assess and Restore interventions across five areas: screening, assessment, navigation and placement, care delivery, and transitions home. Concurrently, in the spring/summer of 2013, the RCA was engaging rehabilitative care system stakeholders to develop the work plan and deliverables for the RCA’s first two-year mandate. Among the key priorities identified was the need to develop a provincial approach to support operationalization of an Assess and Restore philosophy with a particular focus on the needs of frail senior/medically complex populations. In the RCA’s first mandate, the Frail Senior/Medically Complex (FS/MC) Task and Advisory Groups were given the mandate to develop a rehabilitative care approach for frail senior/medically complex populations to support operationalization of priority elements of the Assess and Restore Framework. Specifically, this group was tasked with developing recommendations to support an evidence-based, cross continuum, rehabilitative care approach, for frail senior/medically complex populations who have experienced recent and reversible functional decline that threatens their independence by developing a standardized cross continuum process to support these individuals with restorative potential to access the level of rehabilitative care that is required to safely and most efficiently address their functional goals. Deliverables of this group included: April 14, 2015 (DRAFT) 1 Development of a standardized ‘Provincial Priority Process to Support Direct Admissions to Bedded Levels of Rehabilitative Care from the Community/ED’ Development of a ‘Priority Process Toolkit’ including tools to support operationalization of the provincial ‘Priority Process’ Identification of the Assessment Urgency Algorithm as a Standardized Provincial Screening Tool for the target population of the ‘Priority Process’ Identification of the ‘Provincial Standard Referral Form’ as the referral form to be piloted to determine its feasibility/appropriateness for use in support of the ‘Priority Process’ Development of process and outcome evaluation indicators Creation of a ‘Compendium of Rehabilitative Care Best Practices’ to Support the Assessment and Treatment of the Geriatric Syndromes’ that may contribute to functional decline/frailty Mandate Guided by evidence and data and informed by stakeholder engagement, members of the A&R/FSMC Task Group will support the Rehabilitative Care Alliance’s priority to: Provide project management support to the LHINs to guide their implementation of standardized RCA tools, processes and frameworks developed through the first mandate related to the Frail Senior & Medically Complex initiative. Support the LHINs in their implementation of the Assess and Restore Guideline and support evaluation and knowledge exchange events of A&R funded1 initiatives. Support the LHINs using A&R funds to pilot the RCA standardized process for direct referral / admission to bedded levels of rehabilitative care from the community Deliverables The following are anticipated deliverables for this initiative. These may be subject to change depending on the discussions of the task group and the potential influence of other provincial initiatives. Any significant change in deliverables will be discussed with the task group and Steering Committee. 1. Implementation and evaluation of the standardized tools and indicators developed from the RCA’s first mandate that support the RCA’s ‘Direct Access Priority Process’ to access rehabilitative care from the community as piloted by LHINs with their A&R funding. 2. Revisions (as required) to the standardized tools and indicators developed from the RCA’s first mandate that support the RCA’s ‘Direct Access Priority Process’ to access rehabilitative care from the community as informed by the evaluations/findings from the LHIN funded A&R initiatives 3. Summary analysis of the system impact of Assess and Restore funding and the RCA’s ‘Direct Access Priority Process’. 4. Development of an annual report describing: progress of coordinated LHIN efforts to implement the Assess and Restore Guideline on-going evaluation of LHINA&R funded initiatives and the RCA’s ‘Direct Access Priority Process’ completed knowledge exchange events in support of A&R funded initiatives 1 In 2014-2015 the Ministry of Health and Long-Term Care announced $10.7 million in one-time funding across the 14 LHINs in 14/15, 15/16 and 16/17 to support implementation of the Assess and Restore Guideline April 14, 2015 (DRAFT) 2 Summary and analysis of progress across system and project indicators and lessons learned/successes across LHINs Note: The Task and Advisory Groups will align their work with other Alliance and system initiatives wherever possible and engage in consultations with other groups as needed. Working Group Structure, Roles and Responsibilities Mandate/deliverables will be accomplished through the work of three working groups (see Figure 1): Name of Role of Working Which Deliverable Supporting? Chair Working Group Group Support the LHINs First deliverable: using A&R funds to Implementation and evaluation of the pilot the RCA standardized tools and indicators Direct Access standardized process developed from the RCA’s first mandate Carol Halt Priority Process for direct referral / that support the RCA’s ‘Direct Access Working Group admission to bedded levels of rehabilitative Priority Process’ to access rehabilitative care from the community care from the community. Support achievement of objectives set out by the Ministry in Provincial Assess Assess and Restore Second deliverable: Identification of and Restore LHIN funding letters as well standardized metrics to support system Mark Leads level evaluation of Assess and Restore as support the LHINs Edmonds Implementation in their initiatives. Working Group implementation of the Assess & Restore Guideline and associated funding Second deliverable: i. Support the Direct Revisions (as required) to the standardized Access Priority tools and indicators developed from the Process’ Working RCA’s first mandate that support the RCA’s Group in achievement of its ‘Direct Access Priority Process’ to access deliverables. rehabilitative care from the community as Dr. ii. Provide content informed by the evaluations/findings from A&R /FSMC Task Joanne expertise into any the LHIN funded A&R initiatives Group Clarke review/revisions of the RCA tools Third deliverable: required as a result Development of an annual report of the evaluations/ describing: findings from the Progress of coordinated LHIN efforts to LHIN funded A&R implement the Assess and Restore initiatives Guideline April 14, 2015 (DRAFT) Meeting Frequency Monthly or as required Quarterly or as required Quarterly or as required 3 On-going evaluation of A&R funded initiatives and the RCA’s ‘Direct Access Priority Process’ Completed knowledge exchange events in support of A&R funded initiatives. Summary and analysis of progress across system and project indicators and lessons learned/successes across LHINs A&R /FSMC Advisory Group (Note: The Advisory Group includes members of the Task Group) Accountable to the A&R /FSMC Task Group for fulfilling its mandate and producing the deliverables (as described above) by the agreed upon timelines. Receive updates regarding progress towards objectives/deliverables and to provide feedback regarding next steps. Note: Feedback from the Advisory Group will be given due consideration; however, the A&R/FSMC Task Group will make final determination on recommendations and deliverables Dr. Joanne Clarke Quarterly Figure 1 – Assess & Restore/Frail Senior Medically Complex Task/Working Group Structure RCA Steering Committee RCA Secretariat A&R/FSMC Task Group Provincial Assess and Restore LHIN Leads Implementation Working Group ‘Direct Access Priority Process’ Working Group A&R /FSMC Advisory Group Accountability The Task Group is accountable to the Rehabilitative Care Alliance Steering Committee for fulfilling its mandate and producing the deliverables (as described above) by the agreed upon timelines. Members of the Provincial Assess and Restore LHIN Leads Implementation Working Group are accountable to their respective LHINs for outcomes and deliverables as per the MOHLTC A&R funding letters. The Rehabilitative Care Alliance Steering Committee will act to support the working groups and remove/eliminate barriers as able to facilitate the work of the group. All groups will be supported by the Rehabilitative Care Alliance Secretariat April 14, 2015 (DRAFT) 4 If a group member shares documents pertaining to the work of the group, the member will provide contextual information to the recipient to explain the purpose of the work, whether the work is in progress vs. completion (i.e. potential to change), as well as any other information that is required to provide clarity around the work and the information contained within the document(s). If members are unable to attend a meeting, members are expected to identify an alternative representative who will attend meetings on their behalf and provide the alternative attendee with information required to support their participation. The alternate will communicate the proceedings, decisions and any actions required to the member. Membership Please see the respective group membership lists - TBD This RCA initiative will be supported by an ‘Implementation LHIN Liaison’ who will: Play a consultative role to the RCA Secretariat regarding the directions of each respective task group. Bring the LHIN perspective to Task and Advisory Group meetings as required Provide the LHIN perspective on LHIN implementation of priority initiative at LHIN Leads Advisory Group and/or LHIN Senior Director meetings upon request/as required Represent LHIN interests at broader stakeholder meetings as required (e.g. MOHLTC, CIHI, HQO etc.) Term The term of this task group is through March 2017 Decision Making Decisions are made by member consensus. Consensus requires focus on working together to achieve agreements. If not all members are present, a quorum (50% +1) must be present to move forward with a recommendation or decision. Minutes Minutes shall be recorded for all meetings and circulated to committee members for dissemination/distribution to relevant stakeholders within each organization. Communication Materials provided in support of Working Group meetings should only be shared with associated background and contextual information. Additionally, these materials should be shared with the understanding that they are draft and have the potential to change. All documents approved for broad distribution will be posted on the Alliance website. April 14, 2015 (DRAFT) 5
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