SE Ontario Clinical Services Roadmap to Restorative Care

Providing Clinical Leadership for a Plan to Improve the Coordination of Care Across the South East Local Health Integration Network (SELHIN)


Dr. John Puxty, Director, Centre for Studies in Aging & Health at Providence Care is the Clinical Lead for the South East Ontario Clinical Services Roadmap (CSR) to Restorative Care.

The CSR’s fundamental objective is to streamline and improve health service delivery to communities in the SELHIN. Through a consultative process between the SELHIN, local hospitals and the Community Care Access Centre (CCAC), the CSR was designed to find better ways of providing improved access to care for residents across this region, to cut down on the red tape patients have to deal with in moving from one caregiver to another and to ensure that hospitals and the CCAC can integrate their services to fill the gaps and deliver a more seamless continuum of care region-wide.

Restorative Care

The restorative care component aims to reduce the impact of non-acute care and "avoidable" acute care in hospitals through the development of a regional, integrated plan. The intent is to improve coordination of care between sectors and providers with a focus on the provision of restorative care (including slow stream rehabilitation, activation, rehabilitation and complex continuing care).


High Risk Screening

A Common High Risk Screening Process is to be implemented at all sites and shared with community partners. This process will flag need for further assessment, review level of support service provision and guide development of restorative care plans and treatment delivery for individuals at risk.

This enhanced assessment and reporting tool will lead to better targeting and coordination of a service delivery plan both inside and outside hospital (primary care and community). It will also guide development of innovative new services such as quick response multidisciplinary ambulatory assessments for high-risk individuals presenting to urgent care and emergency rooms within South East Ontario.

Reducing Avoidable Loss of Function

This priority initiative will ensure that preventable loss of function during hospitalization individuals is reduced. This will include best practice protocols being implemented throughout the SELHIN and support the creation of senior-friendly environments in hospital.

Senior friendly hospital principles will be endorsed by all institutions and action plans developed consistent with the Provincial Senior Friendly Hospital Framework and recent survey of all hospitals in South East Ontario. This includes:

  • Organizational Support
  • Processes of Care
  • Emotional and Behavioural Environment
  • Ethics in Clinical Care and Research
  • Physical Environment