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Hip Fracture - Early Referral Process

The early referral process for hip fracture patients is designed to standardize and enhance access to rehabilitation post-surgery for patients following a hip fracture to facilitate their recovery.

From 2015-17, ten acute care and ten rehab hospital sites across five LHINs implemented the new model. Their goal was to reduce the acute care length of stay from surgery to discharge (to inpatient rehab programs) to an average of six (6) days. Almost all sites approached or surpassed the six-day target for ALOS from surgery to discharge to inpatient rehabilitation. All have sustained their gains. 

Tools and Resources
Case study (Healthcare Quarterly, April 2017) Describes the initiative, preliminary results and lessons learned.
Improving transitions from acute care to rehab: Spreading change across GTA hospital sites A presentation for the Quality Improvement and Patient Safety Forum 2016. The presentation provides a high-level description of the Early Referral Process Initiative for Hip Fracture, progress-to-date and lessons learned by project teams. 
Change Package Overview
(includes all the appendices)
This document, developed to facilitate adoption of the early patient referral quality improvement initiative, describes the change ideas and the model, its origins, the roles and responsibilities of project leads and the GTA Rehab Network, key milestones and implementation steps.  
Key Leads of the New Referral Process Hip Fracture Initiative (Appendix A) List of project leads of each participating hospital site. 
New Referral Process Hip Fracture Initiative Model (Appendix B) This diagram outlines the step-by-step processes and suggested timelines for the two pathways. 
Rehab/LTLD Rehab Admission Criteria Guidelines for Hip Fracture (Appendix C) This document provides a guideline of patient needs that are medically manageable in rehab/LTLD rehab programs and recommended information to include in rehab applications.  
Information Recommended When Completing Rehab (RM&R) Application for Hip Fracture (Appendix D) This tool provides acute care clinicians with a guide on what to include in rehab applications to prevent delays due to requests for information. 
Hip Fracture Rehab Referral Considerations & Referral Decision Tree (Appendix E) This document outlines criteria and/or conditions that may require more consideration during the rehab application process. 
Planning for Your Inpatient Stay in Rehab Following a Hip Fracture (Appendix F) This brochure communicates to patients and their caregivers what to expect across all rehab programs. 
Sustainability and Spread A presentation for IDEAS Alumni by the GTA Rehab Network and Health Quality Ontario quality improvement advisors. The presentation covers lessons learned in rolling out the new early referral process for hip fracture patients and tips on how to support sustainability and spread when introducing QI initiatives.