Guidelines and Resources
| Acute to Inpatient Rehab/CCC | |
| Strategies to reduce requests for information (RFIs) (October 2025) |
This presentation (< 20 minutes) explains why providing clear and consistent referral information is crucial and highlights common areas in the referral form that often lack sufficient information (e.g., inconsistencies, unclear details, missing information). It also provides illustrations of what rehab/CCC receiving sites need to know in order to accept a referral. |
| Referral Process Guideline for Bedded Rehabilitative Care (October 2024) | This updated guideline 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 new criteria for timing of response to referrals, requests for information and ‘admission’ of patients within Resource Matching & Referral (if used). |
| Inpatient Rehab/CCC Referral Tip Sheet (October 2024) | This Tip Sheet supplements information in the GTA Rehab Network’s Referral Process Guideline for Bedded Rehabilitative Care and applies to both paper-based referrals sent by FAX and those submitted through RMR. Adherence to the tips will help to optimize the inpatient Rehab/CCC referral process. |
| Hospital Chronic Care Co-Payment | This link, located on the Government of Ontario website, provides information on the chronic care co-payment. |
| Home and Community Care Support Services | |
| Quick Reference Guide for Optimizing In-Home Rehab Care for Older Adults (April 2023) | Developed in collaboration with the Regional Geriatric Program of Toronto, this guide is for care coordinators with Home and Community Care Support Services (HCCSS) and rehab professionals providing in-home rehab for older adults. It illustrates how senior friendly in-home rehab can optimize the functioning of older adults, maximize their independence and improve their quality of life. |
| Discharge Planning and Inter-Organizational Transfers | |
| Discharge Planning Guidelines for Inpatient Rehabilitative Care (February 2025) | This guideline outlines a standardized approach to promote effective, efficient and consistent discharge planning processes for hospitals that provide high and low intensity inpatient rehab. The guideline includes key considerations for discharge planning, determining estimated date of discharge, and includes discharge readiness indicators and standardized information to provide to patient and care partners upon admission to high or low intensity rehab. |
| Inter-Organizational Transfer of Accountability (TOA) Guideline (June 2019) | 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 (June 2019) | 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. |
| Ontario Health Teams | |
| Specialized Rehabilitation: Guidance for Ontario Health Teams (all populations) (Nov 2021) | This best practice guidance for OHTs provides, simple, evidence-based information to help identify patients who require specialized rehabilitation and refer them appropriately. |
| Rehabilitative Care for Congestive Heart Failure (July 2020)
Rehabilitative Care for Frail Seniors (July 2020) Rehabilitative Care for Chronic Obstructive Pulmonary Disease (July 2020) |
These population-specific guides for OHTs provide evidence-based information on how rehab can help to achieve positive patient outcomes for individuals in primary care, hospital or at home; rehab considerations for these populations in the context of COVID-19; and recommendations to assist OHTs in planning rehabilitative care. |
| Rehabilitative Care: An Essential Component of Connected Care (Sept 2019) | This brief guide for OHTs provides an overview of how rehabilitative care services help patients regain health and quality of life. The guide is also included on the RISE platform for OHTs. |
| Provincial Definitions Frameworks and Resources | |
| Webinar on re-alignment of RM&R with RCA bedded levels of rehabilitative care (Rev. Sept 2018) | GTA Rehab Network webinar provides information to assist those referring from acute care to inpatient rehab/CCC, including the rationale for RM&R re-alignment with the RCA Definitions Framework for Bedded Levels of Rehabilitative Care; RM&R changes; and key features of the bedded levels. |
| Key features of RCA Community-Based Levels of Rehabilitative Care (March 2024) | Key features of each of the community-based levels of rehabilitative care. |
| RCA Definitions Framework for Bedded Levels of Rehabilitative Care (March 2023) | This framework defines four bedded levels of rehabilitative care: Rehabilitation Activation/ Restoration, Short-term and Long-term Complex Medical Management. Updates include separate descriptions for high and low-intensity rehab in the Rehabilitation level; the role of rehab in acute care; use of virtual rehab; and greater clarity on the amounts of therapy in each bedded level. |
| Key features of RCA Bedded Levels of Rehabilitative Care (March 2023) | Key features of the 4 bedded levels of rehabilitative care. |
| RCA Framework for Community-Based Levels of Rehabilitative Care (March 2024) | Framework used across Ontario. Defines two levels of rehabilitative care provided in the community. More resources to support its use are available on the Rehabilitative Care Alliance (RCA) website. |
| Total Joint Replacement | |
| Guidelines for TJR Pre-operative Processes (Rev. Nov 2019) | 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 criteria for Home and Community Care. |
| TJR Outpatient Rehab Model of Care and Process Maps (Rev. Feb 2018) | These process maps include responsibilities for acute care and inpatient rehabilitation to support the smooth transition of patients to outpatient rehabilitation. |
| Other | |
| Environmental Scan of Short-Term Transitional Care Models (October 2020) | An overview of 13 STTCM programs in the GTA and how they integrate rehabilitation in their model of care. |
| Patient Complexity Framework (2017) | A resource developed by the Network and the Toronto Stroke Networks to help providers identify which patients have “complex needs” and would benefit from early discharge planning to facilitate access to rehab and community care. |
