Assess & Restore/Frail Seniors Medically Complex Working Group

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:
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





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
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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
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
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
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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
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
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.
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