Notifications

Toronto Grace Health Centre (TGHC) started accepting post-acute care respiratory rehabilitation referrals through the Resource Matching and Referrals (RM&R) application. The post-acute care respiratory rehabilitation program at TGHC is designed to accommodate patients with complex respiratory needs who require inpatient rehabilitation. The target demographic is patients needing frequent recurrent readmission due to respiratory illness. Patients will receive inpatient general rehabilitation managed under the care of a respirologist. All patients will be transitioned to an outpatient virtual pulmonary rehabilitation if indicated. The program is structured primarily to address patients with COPD who have been admitted to hospital with COPD exacerbation. Other indications include asthma, interstitial lung disease, post-covid lung disease, bronchiectasis, and pulmonary hypertension. Patient with complex medical needs and co-morbidity can be accommodated.

1. Patients with a primary or secondary diagnosis of COPD exacerbation will be prioritized
2. Patients with a history of recurrent exacerbations will be prioritized
3. Patients should have 24-48 hours of clinical stability at the time of referral
4. Patient should have stable or decreasing oxygen requirements over the last 24-48 hours
5. Patients should be at low risk for requiring critical care services based on referring MD's judgement
6. Patients should be agreeable to inpatient rehabilitation with transition to outpatient services
7. Smoking cessation is not mandatory

1. Severe dementia limiting ability to participate in rehabilitation
2. Inability to do exercise due to orthopedic limitations
3. Unstable cardiac disease including unstable angina, unstable PE, unstable arrhythmias, or recent acute coronary syndrome
4. Lack of reliable access to internet (for outpatient rehabilitation)
5. Resting FiO2 > 0.5
6. Patient requires urgent imaging or bloodwork more frequent than once daily
7. Behavioural or social concerns which limit the ability to participate in rehabilitation

The RM&R Program, in conjunction with Michael Garron Hospital, launched a new care type called Prolonged-Ventilation Weaning Centre in RM&R. The Prolonged-Ventilation Weaning Centre is a specialized program for adult Intensive Care Unit (ICU) patients who have stabilized from their acute ICU illness, but remain on a mechanical ventilator for more than 14 days and wish to try to breathe on their own. The program accepts referrals from any Intensive Care Unit (ICU) in Ontario.

RM&R users can now send referrals to the Michael Garron Hospital’s Prolonged-Ventilation Weaning Centre through RM&R.

Further specifics on the admission criteria and referral process can be found here:

• Provincial Prolonged-Ventilation Weaning Centre of Excellence and Long-term Ventilation | Michael Garron Hospital, Toronto East Health Network (MGH/TEHN)
• What is a Prolonged-Ventilation Weaning Centre referral form
• How do I send a Prolonged-Ventilation Weaning Centre referral

1. Complete and send Prolonged-Ventilation Weaning Centre referrals in RM&R
2. If access is required, submit request through your organization’s LRAs and other usual channels

To align with the changes to Home and Community Care Support Services, all references of Toronto Central Local Health Integration Network (TC LHIN) will be replaced by Home and Community Care Support Services Toronto Central (HCCSS or HCCSS-TC). This includes the Care Type name as indicated in the images below:

Users will now select the updated Care Type when sending referrals for Home and Community Care Support Services.

An additional category, Sending Hospital Information, is being added to the Long Term Ventilator Care referral form in preparation for upcoming new features. This field is mandatory and will cause the referral to change from ‘Complete’ to ‘Incomplete’.

Please select Not Applicable under the Sending Hospital Information category.

As of January 19th, 2021, Vermont Square Long Term Care(LTC) home is no longer accepting any new Long Term Care applications. The following changes in RM&R application were made:

• TC – Vermont Square renamed to **Do Not Use**TC – Vermont Square (LTC)
• Access to send referrals to TC – Vermont Square has been removed

Do not add home as a client choice for patients.

Under the "Care Requirements" tab, the ‘Diet’ category will be renamed to:

Referrals that are completed prior to February 26^th, 2021 will be deemed incomplete until the new ‘Diet Texture’ question is answered.

In compliance with the PHIPA annual requirement to renew the End User Agreement, all RM&R users will be prompted to review and accept the terms of end user agreement in order to gain access to the application.

This requirement will only be requested once a year.

West Park has a new Frail Seniors Transition to Home (FSTH) Program

Patients being referred must meet the below criteria:

Program Overview

• Average LOS is 4-6 weeks, high tolerance geriatric rehab experience
• Transdisciplinary team expertise, patients are seen by a Geriatrician and will be followed in the community post discharge if required
• Patients will be referred to LHIN/community supports at the same level they are eligible for according to their geographical LHIN support availability
• Care Coordinator will assist with discharge planning and community transition

Inclusion Criteria

• Age 65+
• Referrals sent by GTA hospitals
• Frail Seniors with an established discharge destination in the community
• Impaired pre-morbid functioning with recent acute decline/deconditioning, but not bed bound
• Multi-system co-morbidities, particularly musculoskeletal, neurological, and/or vascular diseases/conditions
• Medically stable (not requiring acute intervention/monitoring)
• Ability to tolerate a minimum of 1 hour of therapy per day, can be split into 2,-30-45 minute sessions, sitting tolerance 1 hour plus
• Patients with sufficient cognitive ability and motivation to participate in rehabilitation. Clients with mild dementia can be supported
• Patients with infusion therapy can be supported
• Patients with surgical/post procedural wound drains
• Patients on hemodialysis may be considered on a case by case basis
• Patients with visual or hearing impairments are supported

Exclusion Criteria

• Unmanaged responsive behaviours limiting the patient’s ability to participate at the minimum level required by the rehab program
• Patients waiting for LTC, palliative care beds
• Patients with enteral feeds
• Patients with tracheostomy
• Patients requiring ventilation (invasive/non-invasive)
• Patients requiring >50% Oxygen

To align with changes on the GTA Rehab paper referral form, we have added Shoulder surgeries to the Outpatient – TJR care type.

To send a referral for outpatient rehab for shoulder surgeries, users are now able to select this option in the Outpatient – TJR care type.

This will then bring up a new set of options for the user to specify which type of surgery was performed.

We have confirmed that all current Outpatient – TJR service providers are accepting referrals for shoulder surgeries. Users will be able to send the referral as they normally would to any of the available providers.

Due to the rapidly evolving situation related to COVID-19, and to be responsive to the mounting capacity pressures on our acute care system, Ontario Health Toronto Region (OHTR) has made an investment for immediate additional Long-Term Ventilation (LTV) bedded capacity in Toronto.

The bedded capacity is shared across:

• Michael Garron Hospital
• Toronto Grace Health Centre
• West Park Healthcare (Centre of Excellence for Long-Term Ventilation)

In an effort to decant Toronto area ICUs in a way where the greatest system capacity is achieved, OHTR is implementing a centralized process for Long Term Ventilator (LTV) bedded capacity management and creation of a single waitlist. The waitlist will be viewable to hospital partner sites across the region to provide transparency and greater planning capabilities.

Patients who are invasively ventilated with a tracheostomy in place for at least 14 days and medically stable for the past 7 days are eligible to be placed on the centralized waitlist.

Eligibility for transfer would only be determined after an assessment between the referring hospital and the LTV team.

1. Complete and send a Long Term Ventilator Care referral type in RM&R to the LTV team. Instructions are attached and available on our website.
2. Access live waitlist reports found in Custom Reports in the “Reports” Module:
   • LTV Waitlist (no Patient identifiers)
   • LTV Patient List (with patient identifiers, site specific)
3. If access is required please contact our support team listed below.