SE Health Reactivation Model Sarah Tam Lee, PT MSc(PT) Advanced - - PowerPoint PPT Presentation

▶
se health reactivation model
SMART_READER_LITE
LIVE PREVIEW

SE Health Reactivation Model Sarah Tam Lee, PT MSc(PT) Advanced - - PowerPoint PPT Presentation

Apr 16, 2023 140 likes •290 views

SE Health Reactivation Model Sarah Tam Lee, PT MSc(PT) Advanced Practice Leader, Rehab Bethany Kwok, RN BScN MN Advanced Practice Leader- Nursing Sept 2019 1 SE Health 111 Years of forward thinking 9,000 Leaders of Impact 20,000 Home

slide-1
SLIDE 1

1

SE Health Reactivation Model

Sarah Tam Lee, PT MSc(PT) Advanced Practice Leader, Rehab Bethany Kwok, RN BScN MN Advanced Practice Leader- Nursing

Sept 2019

slide-2
SLIDE 2

2

111

Years of forward thinking

9,000

Leaders of Impact

CANA NADA’S L S LAR ARGEST ST DIVERSI SIFIED HEALT LTHC HCARE E COM OMPANY & Y & SOCIAL L ENTE TERPR PRISE

20,000

Home visits a day

SE Health

slide-3
SLIDE 3

3

Integrated, Interdisciplinary Team Collaborative Care Planning Outcome Based Care Client-Centred Care

SE Reactivation Model of Care

Philosophical approach to Care

Older Canadians Living with Frailty

Return to Community Functional Mobility Self Care Client, Family, Caregiver Engagement

slide-4
SLIDE 4

4

SE Reactivation Model of Care

Prog

  • gram

am G Goal

  • als
  • To decrea

ease E e Emer ergen ency D Dep epartm tment visits or readmissions

  • Ret

eturn to to p previous l lev evel el o

  • f f

functi tioning g OR manage ge with new level of functioning

  • Support s

t safe t e transitions and ret eturn to to c community

slide-5
SLIDE 5

5

Clinical Models

SE Health Reactivation Model is tailored to meet the needs of older adults living with frailty in collaboration with our partners

  • Recovery in a facility-based reactivation program
  • A community and person-centred focused approach to optimize capability

and return to community Facility-Based Model

  • Recovery in a controlled, supported ‘like-home’ setting
  • Focused on transitioning Home

Retirement-Home Model Two Stages

  • 1. Recovery in a controlled, supported facility-based setting
  • 2. Transition to an integrated homecare team

Retirement-Home & Homecare Model

slide-6
SLIDE 6

6

Overview of Program

Rehabilitative Activities

  • Group-based

Activities

  • 1:1 interventions

Facility/Recreational Activities

  • Encourage

participation in all activities offered by the Home/Facility Medical Management

  • Nursing Care
  • Primary Care

Provider ADL/IADL Support

  • Personal Support
  • Rehab support

Team Meetings

  • Huddles
  • Rounds

Client & Family/Caregiver Involvement

  • Goal Notebook
  • Family conference
slide-7
SLIDE 7

7

EVALUATION

slide-8
SLIDE 8

8

Client Profile

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% % who doesn’t have an informal caregiver Requires help with IADL such as shopping, banking Requires help with ADLs such as bathing, dressing % who presents with cognitive decline % of individuals with chronic conditions not well managed Fell in Last 30 Days % who exhibits Unsteady Gait % who experience daily pain

Client Profile in SE Reactivation Programs Retirement-Home (n=18) Facility-Based (n=219)

slide-9
SLIDE 9

9

Client Profile

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% % who doesn’t have an informal caregiver Requires help with IADL such as shopping, banking Requires help with ADLs such as bathing, dressing % who presents with cognitive decline % of individuals with chronic conditions not well managed Fell in Last 30 Days % who exhibits Unsteady Gait % who experience daily pain

Client Profile in SE Reactivation Programs Retirement-Home (n=18) Facility-Based (n=219)

slide-10
SLIDE 10

10

Facility Only Model

 8.7 % readmission to Hospital  Average Length of Stay: 45 Days  Improvement of Falls by 29%  Decrease in clients with unsteady gait by 40%  ADL improved by 43%  IADL improved by 61%

slide-11
SLIDE 11

11

Retirement Home Model

 Improved health status by 26%  Decreased falls risk by 27%  Improved strength by 35%  Balance improved by 27%  Improved function by 60%  Improvement in ADL performance by 14%

5 10 15 20 25 30 35 40 Gait Speed (n=36) Timed Up & Go (n=37) 5x Sit Stand (n=6) Functional Reach (n=16) Patient Specifc Functional Scale (n=40) BI Index (n=47) S c

  • r

e

Average Scores for Functional Outcome Measures at Admission and Discharge

Admission Discharge

 8.4% readmission to hospital  Average Length of Stay: 16 days

slide-12
SLIDE 12

12

Patient/Client Feedback

  • SE Health Reactivation program helped me stand from chair, walk

with the walker independently, go to the washroom safely, feed myself and learned a lot to keeping good spirits this program is great and helped me a lot. I can’t wait to go home tomorrow to be with my puppy who ever thought of this program was thinking right! There should be more programs like this in the province to help people in the hospital and I see great progress and I am happy about it Great programs that helped me get through a difficult time and gave me strength and compassion

Satisfaction Survey from the one of our programs: 100% of patients would refer this service to family / friends 100% would participate again

slide-13
SLIDE 13

13

Next Steps for SE Reactivation

Specialized Teams Scalability Building Bridges Evaluation interRAI

Collaborative Model Enhancement

Clinical Innovation

slide-14
SLIDE 14

14

Thank You!

Thank you for your Interest in the SE Reactivation Model To learn more please connect with: Sarah Tam Lee: sarahtamlee@sehc.com Bethany Kwok: bethanykwok@sehc.com www.sehc.com