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SW LHIN Complex Continuing Care Eligibility GuidelinesName:HIN:Referring site:Date:Definition: OHA defines Complex Continuing Care as a specialized program of care providing programs formedically complex patients whose condition requires a hospital stay, regular onsite physician care andassessment and active care management by specialized staff.The patient must be medically complex with a stabilized disease process and predictable outcomes.1. The patient will benefit from being in a complex continuing care unit and has a combination of multiple interacting andunpredictable chronic medical conditions, which require a skilled interdisciplinary team approach.2. The patient requires a long term, progressive, goal-oriented plan of care to reach an optimal level of mental, physical,cognitive and/or social well being.3. The patient and/or substitute decision maker has consented to treatment in the program and demonstrates a willingnessand motivation to participate in the treatment program.4. The patient is not able to be managed in the community by CCAC services, informal care givers and/or other communityservices, is not a candidate for LTC at this time.Eligibility Criteria Checklist Is 18 years or older (pediatric population by exception only) Has a clear diagnosis and co-morbidities identified Is medically and surgically stable, ie. all reasons for acute care stay have been stabilized Has completed all consults and diagnostic tests for the purposes of diagnosis and/ortreatment of acute conditions Has acknowledged and addressed all abnormal laboratory values, as required Has no substance abuse and/or mental health issues, which would limit the patient’sability to participate in the program, and does not demonstrate behaviours that could beharmful to themselves and/or others Has been screened for all infection control concerns Requires more than 3-4 hours of direct care per day, which is primarily delivered by anRN/RPN Has established functional goals, which are specific, measurable, realistic and timely. Has demonstrated the potential to tolerate one 30 minute session of therapy, up to5 days per weekEligible: Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes NoPriority Code (definitions on page 2):Complex Care Referral Types (Referral Type definitions on page 2): Med. Complex End of Life Care Restorative Care Behavioural HealthComments:Signature of Assessor:September 2014Date:

MedicallyComplexPeople with multiplemedically complexConditions, such ascomplex wounds, ALS,MS, bariatric or COPDwho require uniqueprogramming.BehaviouralHealthPeople with dementiaand challengingbehaviours whorequire skilledinterventions in acontrolledenvironment tofacilitate theirtransition to theappropriate level ofcare.End of Life CareRestorative CarePeople with a life limitingillness who are at the endstage of that disease processand who require pain andsymptoms management andskilled interventions deliveredby an interprofessional team.This may include people whorequire chemotherapy as partof their treatment regime tomaintain comforta) Life expectancy of 3monthsb) Patient is on an establishedtreatment regime with afocus on pain and symptommanagement and end of lifecarec) Social supports have beendepleted or are no longeravailabled) Palliative PerformanceScale 50% or lesse) Patient may be experiencingcomplexities associated withthe end stage of their diseaseincluding delirium, aggression,agitation etc.People with a multiplemedical and/or functionallycomplex condition(s) who areexpected to benefit from lowintensity, long durationinterventions provided by aninterprofessional team, withclearly articulated functionalimprovement goals that canbe attained within theaverage length of staya) Min-mental state exam(MMSE) score of 16b) Presence of significantphysical/functionalimpairmentsc) Physical tolerance thatpermits participation inprogrammingd) Goal to go home or to aretirement home.Priority Code DefinitionsPriority 1 “Crisis”- the Patient’s needs can be met in Complex Care and requires immediate admission (within days, not weeks)as a result of a crisis arising from the patient’s condition or circumstances that puts them at significant safety risk if left in theircurrent environment.Priority 2 “Readmission/Change in Stream”- A current Complex Care patient who needs another Complex Care stream, or aprevious Complex Care patient transferred out due to an acute episode and is now medically stable and needs to return to aComplex Care bed.Priority 3 “All Others”- Patient eligible for Complex Care and does not meet the requirements for Priority 1 or 2.FACILITY CHOICESSeptember 2014RANK

SW LHIN Rehabilitation Eligibility GuidelinesName:HIN:Referring site:Date:Definition: According to the World Health organization, Rehabilitation is a progressive, dynamicgoal-oriented and often time- limited process, which enables an individual with impairment to identify andreach his/her optimal mental, physical, cognitive and/or social functional level.1.2.3.4.5.6.The patient has sufficient cognitive skills to set and attain functional goals, demonstrate regular progress, and readily integratenew learning skills into daily life.The patient requires access to inter-professional staff, where periodic changes to the care plan and ongoing re-definition oftherapeutic goals are required.The patient requires a progressive, goal-oriented plan of care to reach an optimal level of mental, physical, cognitive and/orsocial well -being.The patient and/or substitute decision maker has consented to treatment in the program and demonstrates a willingness andmotivation to participate in the rehabilitation program.The patient is not able to be managed in the community by CCAC services, informal care givers and/or other community services,and is not a candidate for LTC at this time.Active treatment that results in the patient’s frequent absences from the unit during the rehabilitation treatment session mustnot interfere with the patient’s ability to participate in the rehabilitation.Eligibility Criteria Checklist Is 18 years or older (pediatric population by exception only) Has a clear diagnosis and co- morbidities identified Is medically and surgically stable, ie. all reasons for acute care stay have been stabilized and/orreached a plateau Has completed all consults and diagnostic tests for the purposes of diagnosis or treatment ofacute conditions Has acknowledged and addressed all abnormal laboratory values, as requiredHas no substance abuse and/or mental health issues, which would limit the patient’sability to participate in the program, and does not demonstrate behaviours that could be harmful tothemselves and/or others Has been screened for all infection control concerns Has established functional goals, which are specific, measurable, realistic and timely Is able to sit for 1 hour, 2- 3 times per day, and tolerate 2 therapies per day Is committed to returning to the community, utilizing family and/or community supportservices, as required Has a documented discharge destination Has a follow-up plan in place at the time of referral, and follow-up appointments scheduledby the acute site at the time of discharge Has determined special equipment needsEligible: Yes NoPriority Code (definitions on page 2):Comments:Signature of Assessor:January 2015Date: Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Priority Code DefinitionsPriority 1 “Crisis”- the Patient’s needs can be met in Rehabilitation and requires immediate admission (within days,not weeks) in order to optimize Rehab outcomes. This includes Acute Stroke patients.Priority 2 “Readmission/Change in Stream”- A current Rehabilitation patient who needs another Rehabilitationstream, or a previous Rehabilitation patient transferred out due to an acute episode and is now medically stable andneeds to return to a Rehabilitation bed.Priority 3 “All Others”- Patient eligible for Rehabilitation and does not meet the requirements for Priority 1 or 2.FACILITY CHOICESJanuary 2015RANK

Acute Care to Rehab & ComplexContinuing Care (CCC) ReferralInsert Health Service Provider LogoIdentify Referral Destination:Referral to RehabPatient IdentificationReferral to Complex Continuing Care (CCC)If Faxed Include Number of Pages (Including Cover): PagesEstimated Date of Rehab/CCC Readiness: DD/MM/YYYYPatient Details and DemographicsHealth Card #:Version Code:Province Issuing Health Card:No Health Card #:No Version Code:Surname:Given Name(s):No Known Address:Home Address:City:Postal Code:Country:Province:Telephone:Alternate Telephone:No Alternate Telephone:Current Place of Residence (Complete If Different From Home Address) :Date of Birth: DD/MM/YYYYGender:Patient Speaks/Understands English:Primary Language:EnglishFrenchYesMNoFOtherInterpreter Required:Marital Status:YesNoOtherPrimary Alternate Contact Person:Relationship to Patient(Please check all applicable boxes) :Telephone:POASDMSpouseAlternate Telephone:Secondary Alternate Contact Person:Telephone:POASDMSpouseAlternate Telephone:N/A:OtherNo Alternate Telephone:Program Requested:Current Location Name:Current Location Address:Province:Postal Code:Current Location Contact Number:No Alternate Telephone:None Provided:Relationship to Patient(Please check all applicable boxes) :Insurance:OtherBed Offer Contact (Name):City:Bed Offer Contact Number:Page 1 of 7FINAL Rehab and CCC Provincial Referral Standards for Provincial Implementation March 14, 2014Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)

Acute Care to Rehab & ComplexContinuing Care (CCC) ReferralInsert Health Service Provider LogoPatient IdentificationMedical InformationPrimary Health Care Provider (e.g. MD or NP)Surname:Given Name(s):NoneReason for Referral:Allergies:No Known AllergiesInfection Control:NoneYes --- If Yes, List Allergies:MRSAVREAdmission Date: DD/MM/YYYYCDIFFESBLTBDate of Injury/Event: DD/MM/YYYYOther (Specify):Surgery Date: DD/MM/YYYYRehab Specific Patient Goals:CCC Specific Patient Goals:Nature/Type of Injury/Event:Primary Diagnosis:History of Presenting Illness/Course in Hospital:Current Active Medical Issues/Medical Services Following Patient:Past Medical History:Height:Weight:Is Patient Currently Receiving Dialysis:YesNoPeritonealHemodialysis Frequency/Days:Location:Is Patient Currently Receiving Chemotherapy:YesNoFrequency: Duration:Location:Page 2 of 7FINAL Rehab and CCC Provincial Referral Standards for Provincial Implementation March 14, 2014Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)

Acute Care to Rehab & ComplexContinuing Care (CCC) ReferralInsert Health Service Provider LogoPatient IdentificationIs Patient Currently Receiving Radiation Therapy:YesNoFrequency: Duration:Location:Concurrent Treatment Requirements Off-Site:YesNoDetails:CCC SpecificMedical Prognosis:ImproveServices Consulted:PTPending Investigations:Remain StableOTYesSWNoDeterioratePalliativeUnknown Palliative Performance Scale:Speech and Language PathologyNutritionOtherDetails:Frequency of Lab Tests:UnknownNoneRespiratory Care RequirementsDoes the Patient Have Respiratory Care Requirements?:YesNo -- If No, Skip to Next SectionYesNoSupplemental Oxygen:YesNoVentilator:Breath oPatient Owned:YesNoBi-PAP:YesNoRescue Rate:YesNoYesNoCufflessPatient Owned:YesNoAdditional Comments:IV TherapyIV in Use?:YesNo -- If No, Skip to Next SectionIV Therapy:YesNoCentral Line:YesNoPICC Line :YesNoSwallowing and NutritionSwallowing Deficit:YesNoSwallowing Assessment Completed:YesNoType of Swallowing Deficit Including any Additional Details:TPN:Enteral Feeding:Yes (If Yes, Include Prescription With Referral)YesNoNoPage 3 of 7FINAL Rehab and CCC Provincial Referral Standards for Provincial Implementation March 14, 2014Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)

Acute Care to Rehab & ComplexContinuing Care (CCC) ReferralInsert Health Service Provider LogoPatient IdentificationSkin ConditionSurgical Wounds and/or Other Wounds Ulcers:YesNo -- If No, Skip to Next Section1. Location:Stage:Dressing Type:(e.g. Negative Pressure Wound Therapy or VAC)Frequency:Time to Complete Dressing:Less Than 30 MinutesGreater Than 30 Minutes2. Location:Dressing Type:(e.g. Negative Pressure Wound Therapy or VAC)Time to Complete Dressing:Stage:Frequency:Less Than 30 MinutesGreater Than 30 Minutes3. Location:Dressing Type:(e.g. Negative Pressure Wound Therapy or VAC)Time to Complete Dressing:Stage:Frequency:Less Than 30 MinutesGreater Than 30 Minutes* If additional wounds exist, add supplementary information on a separate sheet of paper.ContinenceIs Patient Continent?:YesNo -- If Yes, Skip to Next SectionBladder Continent:YesNoIf No:Occasional IncontinenceIncontinentBowel Continent:YesNoIf No:Occasional IncontinenceIncontinentPain Care RequirementsDoes the Patient Have a Pain Management Strategy?:Controlled With Oral Analgesics:YesNoMedication Pump:YesNoEpidural:YesNoHas a Pain Plan of Care Been Started:YesNoYesNo -- If No, Skip to Next SectionCommunicationDoes the Patient Have a Communication Impairment?:YesNo -- If No, Skip to Next SectionCommunication Impairment Description:Page 4 of 7FINAL Rehab and CCC Provincial Referral Standards for Provincial Implementation March 14, 2014Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)

Acute Care to Rehab & ComplexContinuing Care (CCC) ReferralInsert Health Service Provider LogoPatient IdentificationCognitionCognitive Impairment:YesNoUnable to Assess -- If No, or Unable to Assess, Skip to Next SectionDetails on Cognitive Deficits:Has the Patient Shown the Ability to Learn and Retain Information:Delirium:YesYesNo -- If No, Details:No -- If Yes, Cause/Details:History of Diagnosed Dementia:YesNoBehaviourAre There Behavioural Issues:YesNo -- If No, Skip to Next SectionDoes the Patient Have a Behaviour Management Strategy?:Behaviour:YesNoNeed for Constant ObservationVerbal AggressionPhysical AggressionAgitationSun downingExit-SeekingResisting CareOtherWanderingRestraints -- If Yes, Type/Frequency Details :Level of Security:Non-Secure UnitSecure UnitWander GuardOne-to-oneSocial HistoryDischarge ment Home (Name):Accommodation Barriers:Smoking:YesUnknownNo Details:Alcohol and/or Drug Use:YesNo Details:Previous Community Supports:YesNoDetails:Discharge Planning Post Hospitalization Addressed:YesNo Details:Discharge Plan Discussed With Patient/SDM:YesNoPage 5 of 7FINAL Rehab and CCC Provincial Referral Standards for Provincial Implementation March 14, 2014Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)

Acute Care to Rehab & ComplexContinuing Care (CCC) ReferralPatient IdentificationInsert Health Service Provider LogoCurrent Functional StatusSitting Tolerance:More Than 2 Hours Daily1-2 Hours DailyLess Than 1 Hour DailyHas not Been UpTransfers:IndependentSupervisionAssist x1Assist x2Mechanical LiftAmbulation:IndependentSupervisionAssist x1Assist x2UnableNumber of Metres:Weight Bearing Status:Bed Mobility:FullIndependentAs ToleratedPartialToe TouchSupervisionAssist x1NonAssist x2Activities of Daily LivingLevel of Function Prior to Hospital Admission (ADL & IADL) :Current Status – Complete the Table Below:ActivityIndependentCueing/Set-upor SupervisionMinimum AssistModerate AssistMaximum AssistTotal CareEating:(Ability to feed self)Grooming:(Ability to washface/hands, comb hair,brush teeth)Dressing:(Upper body)Dressing:(Lower body)Toileting:(Ability to self-toilet)Bathing:(Ability to wash self)Page 6 of 7FINAL Rehab and CCC Provincial Referral Standards for Provincial Implementation March 14, 2014Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)

Acute Care to Rehab & ComplexContinuing Care (CCC) ReferralPatient IdentificationInsert Health Service Provider LogoSpecial Equipment NeedsSpecial Equipment Required:HALOOrthosisYesBariatricNo -- If No, Skip to Next SectionOtherPleuracentesis:YesNoNeed for a Specialized Mattress:YesParacentesis:YesNoNegative Pressure Wound Therapy (NPWT):NoYesNoRehab SpecificAlphaFIM InstrumentIs AlphaFIM Data Available:YesNo -- If No, Skip to Next SectionHas the Patient Been Observed Walking 150 Feet or More:If Yes – Raw Ratings (levels 1-7):If No – Raw Ratings (levels 1-7):Projected:YesNoTransfers: Bed, ChairExpressionTransfers:ToiletBowel ManagementLocomotion: WalkMemoryEatingExpressionTransfers:ToiletBowel ManagementGroomingMemoryFIM projected Raw Motor (13):FIM projected Cognitive (5):Help Needed:AttachmentsDetails on Other Relevant Information That Would Assist With This Referral:Please Include With This Referral:Admission History and PhysicalRelevant Assessments (Behavioural, PT, OT, SLP, SW, Nursing, Physician)All relevant Diagnostic Imaging Results (CT Scan, MRI, X-Ray, US etc.)Relevant Consultation Reports (e.g. Physiotherapy, Occupational Therapy, Speech and LanguagePathology and any Psychologist or Psychiatrist Consult Notes if Behaviours are Present)Completed By:Contact Number:Title:Direct Unit Phone Number:Date: DD/MM/YYYYAlphaFIM and FIM are trademarks of Uniform Data System for Medical Rehabilitation (UDSMR), a division of UB Foundation Activities, Inc. All Rights Reserved.The AlphaFIM items contained herein are the property of UDSMR and are reprinted with permission.Page 7 of 7FINAL Rehab and CCC Provincial Referral Standards for Provincial Implementation March 14, 2014Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)