The Home Rehabilitation Team is located within the Medicine Hat Regional Hospital and it provides short-term, intensive, interdisciplinary rehabilitation in clients’ homes (i.e. houses, lodges, group homes and/or level B supportive living) to support recovery after a recent decline in independence, function and mobility.
This program only accepts referrals for those living within Medicine Hat Home Care boundaries.
Our team has occupational and physical therapy, nursing, social work, recreation therapy, and therapy assistants. Professionals assess and create one unified treatment plan. Therapy Assistants provide therapy with all professionals working to full scope of practice to fill in treatment as needed. There is no wait list but treatment intensity varies between 3-5 days per week for 45-60 minutes up to 12 weeks.
Quarterly scorecards collect outcomes and the AHS Community Rehabilitation Dashboard collects other measures; outcomes used to drive QI projects every 12-18 months. Compensation through AHS Allied Health community budgets in Medicine Hat.
How It Starts
Every staff member builds understanding of the principles of the transdisciplinary model (i.e. how the patient guides the whole process and is an active partner in their care) and how many of their interventional roles are transferrable to family members in the home setting and therefore to other professionals. They also build confidence and comfort in doing other discipline treatment plans through direct training by the other professional and shadowing of that same professional or the Therapy Assistant in joint sessions.
Everyone is trained in the administration of the COPM (“Canadian Occupational Performance Measure”) and the expectation it is used as a means of identifying goals with every HRT patient and family.
At rounds, everyone contributes to the planning and updating of the patient’s treatment plan based upon their progress as well as in staff planning for absences so colleagues can offer support where needed for ongoing treatment and ensure minimal disruption to patient care. Goals and treatment plans are documented within the patient’s Connect Care chart and it is readily apparent how each discipline adds components to potentially every goal the patient has brought forward.
Team processes are written out and regularly reviewed by the team and the team undergoes a quality improvement review about every 12-18 months depending upon feedback from patients and families or challenges that arise in the program. Everyone on the team is expected to pick up new referrals as they come in the work-queue and complete meet and greets as well as book intakes.
From 2023-2026 fiscal years, new referrals are booked within 2.5 business days with an intake. HRT clients reach their identified goals 98% of the time prior to discharge and do so on average within 26 business days; this is measured by use of the Canadian Occupational Performance Measure (pre & post). 94% of these clients maintain their goals three to six months after their discharge and only 1% of them are readmitted to hospital with diagnosis of failure to thrive, fracture or falls within one month of HRT discharge.
As per the AHS Community Rehabilitation Dashboard, HRT is 88% effective in facilitating improvements in their clients’ quality of life (target is 60%). The average Albertan reports a quality-of-life score of 77.4; HRT clients on average report quality of life at 53.8 prior to commencing services and upon discharge, report their score to be at 74.2. This is a 20.4 index change where only a change of 7 points is considered significant. HRT shows the double the rate of change in quality of life compared to all its counterparts within the AHS Community Rehabilitation Dashboard.
94% of HRT clients would recommend this service to their friends and family as per patient engagement survey results.
This team is highly successful because of the transdisciplinary model they function within, the consistent practice model driven by outcome measures and the naturally challenging environment of the home setting.
Patients are able to be discharged from acute care or inpatient rehabilitation units quicker and return to their comfort of their home. They can receive intensive rehabilitation in that home setting where professionals can also problem solve with them through real-world challenges and ensure they can reintegrate back into the community setting. Rehabilitation in the home tends to lead to greater gains in shorter periods of time due to the constant demands of daily activities on the patient’s mobility, self care and cognitive/mental health.
How It Works
All patients referred to the program first undergo a meet and greet process, either in-person in the hospital or over the phone if they are not admitted to hospital. The team reviews with them at a high level what their concerns are and how that matches up with the various disciplines involved in the team. If the patient meets HRT criteria, the staff member then explains the intake process in the home whereby 1-2 professionals complete an interview, begin the goal setting process (including scoring of baseline performance and satisfaction & quality of life index) and their individual discipline assessments.
They bring to the intake a client binder which serves as the activity hub between the patient and the team. This binder includes photos and brief summaries of each discipline’s role, a booking calendar and other key resources (i.e. how to contact our office, common community support phone numbers/addresses, exercise handouts). Following the intake, subsequent professionals are booked for assessments and a Therapy Assistant is assigned the overall care interventions to carryout with the patient. Usually by end of week 2, all professionals have entered the home and developed rapport with the patient and family. A copy of the patient’s goals are then printed following weekly HRT rounds and the Therapy Assistant brings them to the client’s home to put in the client binder for future reference.
Appointments are booked 3-5 times per week with the patient with various staff members filling in the treatment sessions for that patient depending upon caseload demands and staffing (so not strictly the Therapy Assistant).
