Team profiles :

GTA Rehab Network (UHN)

At a Glance   

Region: Ontario

Setting: Urban

EAIP program principle(s): 

• Access to specialized healthcare services 
• Access to social and community supports 
• Access to system navigation and support 

Implementation (new, spread, and/or expand):   

• Expand 

Team Profile  

The organizations collaborating to support this program include the University Health Network – GTA Rehab Network, Toronto Paramedic Services, North Western Toronto (NWT) Ontario Health Team (OHT), Regional Geriatric Program (RGP) of Toronto, Black Creek Community Health Centre, Unison Health & Community Services, LOFT Community Services, Lumacare, Humber River Health, Emery-Keelesdale Nurse Practitioner-Led Clinic, Runnymede Healthcare Centre. The team members include subject matter experts, paramedicine team leads, nursing leadership, directors, and project managers who support measurement and evaluation. 

Community

• This initiative supports the North and West regions of Toronto that are served by the North Western Toronto (NWT) Ontario Health Team (OHT). 
• NWT OHT communities have the highest proportion of seniors in Ontario and significant visible minority and newcomer populations facing socioeconomic challenges. 
• Among those living in this region, 61% of the population identify as visible minorities, while 54% are newcomers, and 50% speak English as a second language. Additionally, 22% of households are low-income, and 48% of adults aged 65 and older live alone with difficulties in Activities of Daily Living (ADLs), compared to the Ontario average of 46%. 
• The number of adults aged 65 and older in this area is projected to nearly double in the next 20 years, highlighting the need to adapt programs to meet increasing demands. 

Program Focus 

Program Description  

• This secondary prevention program aims to extend the time that older adults can live healthy and independently in the community by improving access to rehabilitation services for older adults who have had a fall and did not go to the hospital, through the implementation of post-fall care pathways initiated by community paramedics. Specifically, the care pathway will: 
  • evaluate the rehabilitative needs of older adults who have had a fall or who report a fall, but who did not require transfer to a hospital (lift-assist/no-admit), using a set of screening tools, and;  
  • refer older adults to an appropriate stream of services to help prevent future falls.  

Implementation Approach:

• Pathways redesign: Redesign community paramedic practices for lift-assist/no-admit situations by introducing a post-fall rehabilitative care pathway based on multifactorial screening evaluations. Pathway streams may include three “levels”, based on intensity of services: community intervention (level 1), Outpatient community clinic/in-home care/specialized geriatric services (level 2), or in-patient rehabilitation services (level 3).   
• Comprehensive Geriatric Orientation: Provide comprehensive geriatric orientation and education to community paramedics. 
• Inventory of Post-fall Pathway Services: Create an inventory of post-fall pathways in the NWT OHT for geriatric rehabilitative care services and streamline referral processes, including developing a direct access pathway to inpatient rehabilitative programs from the community.