Improving flow between hospitals and community
Confusion about community services for patients with ABI has resulted in concern that ABI clients are not being referred or triaged to the right programs.
In the fall, the Network brought acute care, rehab and community-based partners together to share information on services available in the community and identify mechanisms to improve flow between hospital and community.
Participants learned that:
- Central CCAC and Toronto Central CCAC have ABI Programs with a dedicated ABI Case Manager with a caseload that includes clients with complex ABI that requires active rehabilitation.
- Other CCACs in the GTA do not have a specific ABI Program at the present time. Clients with an ABI in those regions must access services through the general CCAC program.
- Community services in North Simcoe Muskoka (NSM) are available through the NSM ABI Collaborative, made up of four LHIN-funded agencies: North Simcoe Muskoka CCAC; York Simcoe Brain Injury Services; Brain Injury Services Muskoka Simcoe; and March of Dimes Canada.
Participants also identified several key issues:
- More clarity is needed on the referral and intake process for ABI CCAC referrals;
- Potential duplication exists between the RM&R and Toronto ABI Network referral process; and
- Better identification of ABI clients is required during the CCAC referral process to ensure they access appropriate ABI resources.
Since this forum, the Toronto ABI Network secretariat held follow up discussions with CCAC representatives to provide clarity on the referral process and will continue to work with representatives from the hospital sector and the CCAC to review the referral process to ABI-specific programs within the CCACs and to identify opportunities for improvement.