Required Medical Stability
- The patient is medically and surgically stable. All reasons for acute care stay have been stabilised and/or care goals reached, so that all care can be safely managed with the resources available in a post-acute care setting.
- Vital signs are stable.
- All consults and diagnostic tests ordered for the purposes of diagnosis or treatment of acute conditions are complete or can be accessed once patient is at Providence Care without major barriers or access issues.
- All abnormal laboratory values have been acknowledged and addressed in the acute care setting.
- There is a clear diagnosis and care plan for acute issues should they arise.
- Relevant comorbidities have been identified and optimized.
- There are no acute medical issues, e.g.,:
• No SOB, CHF significantly limiting ability to participate.
• C-PAP, BiPAP settings are stable on complex medical, ventilated patients.
• Weaning of Oxygen and trach discontinuation when appropriate.
- Medication needs are determined pre-transfer.
- Referral to SMOL program resulted from care plan established with patient and family/SDM
- If there is a terminal diagnosis, the prognosis is long enough to result in meaningful outcomes
Readiness and Eligibility
- The patient has potential (based on clinical assessment and expertise) to improve in functional and benefit from rehabilitative care.
- The patient is able to participate in and benefit from rehabilitative care (eg. carry-over for learning) within the context of his/her specific functional goals and the parameters of the program/service.
- The patient has sufficient cognitive ability to determine functional goals, make regular progress and readily integrate new learning into rehabilitation and daily life. Patient/family has functional goals that are specific, measurable, realistic and timely.
- Any behavioral or mental health issues which can be managed through strategies, resources and modifications, and do not limit the patient’s ability to participate in therapy and/or their care.
- The Patient’s needs cannot be met in community programs/services.
- The goal and expectation is that the Patient will be returning to the community, using family and/or community support services as required.
Admission Criteria: Age 65 or older with a constellation of clinical issues related to the frail elderly but medically stable with a clear diagnosis care plan for acute issues and established comorbidities. Patient must be able to participate in progressing from low to high tolerance therapy from a minimum of 15-30 minutes per day up to 2 hours per day, 5 days per week. Provides inter-professional clinical assessment, consultation, recommendation and rehabilitation and community reintegration to frail seniors with complex health needs.