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Guidelines and Resources

Acute to Inpatient Rehab/CCC
Hospital Chronic Care Co-Payment: Questions and Answers This link, located on the Ministry of Health and Long-Term Care website, provides information on the chronic care co-payment.
Referral Guideline for Bedded Levels of Rehabilitative Care (July 2019) This updated guideline is in alignment with the provincial Definitions Framework for Bedded Levels of Rehabilitative Care. It provides criteria to determine eligibility for bedded/inpatient rehabilitative care, including criteria for rehab readiness, ALC designation, and timing and number of referrals to submit. It also includes response categories for submitted referrals.  
Discharge Planning Guidelines for Inpatient Rehabilitation These guidelines provide guiding principles, standards and discharge readiness criteria for inpatient high tolerance and low tolerance rehab programs. 
Patient Information Letter for patients referred to inpatient rehab/LTLD rehab This letter is used during discharge planning discussions if a patient is being referred to a rehab/CCC hospital for inpatient rehab/LTLD rehab programs. 
Hip Fracture
Outpatient Rehabilitation Model of Care for Patients Post-Hip Fracture This model of care represents optimal care based on existing evidence and expert opinion. 
Total Joint Replacement
Guidelines for TJR Pre-operative Processes This guideline includes processes in the pre-operative, acute care admission and outpatient rehabilitation phases; pre-operative triage considerations for referral to outpatient/inpatient rehabilitation; and referral critiera for CCAC.
TJR Outpatient Rehab Model of Care and Process Maps These process maps include responsibilities for acute care and inpatient rehabilitation to support the smooth transition of patients to outpatient rehabilitation. 
Inter-Organizational Transfer of Accountability (TOA) Guideline
Inter-Organizational Transfer of Accountability (TOA) Guideline This guideline provides six principles that support the interactive process of transferring information and coordinating follow-up care between organizations across the patient lifespan and care continuum. 
Discharge Information Checklist This checklist outlines key information that should be provided at the time of transfer to the next level of care (to hospital or community) in order to support patient safety and continuity of care.