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Stroke & Brain Injury Early Supported Discharge Program   at
Sheldon M. Chumir Health Centre
Specialty: Rehabilitation
Connect Care Department: CGY SMCC ESD
Estimated time to routine appointment: Within 2 weeks
Alberta Health Services - Calgary Zone
SERVICE DESCRIPTION
The Calgary Early Supported Discharge (ESD) Program is a time-limited, home-based and community rehabilitation service for patients.The Calgary ESD Program takes referrals from Calgary acute care sites and tertiary rehabilitation programs (i.e., FMC Tertiary Neurorehabilitation Program or Dr. Vernon Fanning Neuro Rehab Program).

The ESD Program works collaboratively with patients and their families to support the rehabilitation journey by:
  • facilitating functional recovery and enabling independence with mobility, activities of daily living, communication and/or community integration by participating in your daily life activities and doing your regular roles at home and in the community
  • providing education to patients and families or other close supports
  • counselling patients and families through their injury / illness adjustment
The average length of service is 6-weeks but may be shorter or longer based on patient-need.
The Calgary Early Supported Discharge (ESD) Program is a time-limited, home-based and community rehabilitation service for patients.The Calgary ESD Program takes referrals from Calgary acute care sites and tertiary rehabilitation programs (i.e., FMC Tertiary Neurorehabilitation Program or Dr. Vernon Fanning Neuro Rehab Program).

The ESD Program works collaboratively with patients and their families to support the rehabilitation journey by:
  • facilitating functional recovery and enabling independence with mobility, activities of daily living, communication and/or community integration by participating in your daily life activities and doing your regular roles at home and in the community
  • providing education to patients and families or other close supports
  • counselling patients and families through their injury / illness adjustment
The average length of service is 6-weeks but may be shorter or longer based on patient-need.
ELIGIBILITY REQUIREMENTS
Inclusion criteria:
  • Patient is diagnosed with a recent stroke, brain injury or spinal cord injury
  • Patient is living in the City of Calgary and extending up to 25 km beyond city limits
  • Patient is at least 18 years of age or older
  • Patient’s discharge is to a home environment
  • Patient is actively participating in rehabilitation
  • Patient demonstrates emerging awareness and ability to carry-over new information
  • Treatment is required in home environment/community to apply and transfer skills
  • Patient has supports in place and is not dependent on the ESD team for safety
  • Single discipline referrals will be considered
Exclusion Criteria
  • Community referrals and self-referrals are not accepted.
  • Discharge is to a long-term care setting
  • Behaviours or concerns regarding client or environment that are limiting to rehabilitation and/or a risk for staff to enter the home
  • Client has rehabilitation goals that are better met in other rehabilitation programs (e.g. return to work, driving, slow recovery progress, need for specialized equipment, etc.)
Inclusion criteria:
  • Patient is diagnosed with a recent stroke, brain injury or spinal cord injury
  • Patient is living in the City of Calgary and extending up to 25 km beyond city limits
  • Patient is at least 18 years of age or older
  • Patient’s discharge is to a home environment
  • Patient is actively participating in rehabilitation
  • Patient demonstrates emerging awareness and ability to carry-over new information
  • Treatment is required in home environment/community to apply and transfer skills
  • Patient has supports in place and is not dependent on the ESD team for safety
  • Single discipline referrals will be considered
Exclusion Criteria
  • Community referrals and self-referrals are not accepted.
  • Discharge is to a long-term care setting
  • Behaviours or concerns regarding client or environment that are limiting to rehabilitation and/or a risk for staff to enter the home
  • Client has rehabilitation goals that are better met in other rehabilitation programs (e.g. return to work, driving, slow recovery progress, need for specialized equipment, etc.)
REFERRAL SUBMISSION INSTRUCTIONS
Follow these steps before sending a referral. Incomplete referrals may be returned or declined.
  1. Referring providers must be an Allied Health Professional (OT, PT, SLP, Rec T).
  2. Read the Service Description and Eligibility Requirements to ensure your patient is appropriate for this service.
  3. Read the Referral Guidelines table below to find the reason why you are referring to this service.
  4. Click the (+) on the Referral Guidelines table below to ensure you the applicable required information and investigations to accompany the referral before submission. Review the applicable referral processes below and follow the instructions to submit the referral.
Urgent Referral Process
Urgent referrals are only accepted from acute care units.
Urgent referrals submitted by 1:00 pm on the same day of patient discharge will be triaged by the end of the business day. Urgent referrals submitted AFTER 1:00 pm on the same day of patient discharge will be triaged the next business day.
Follow these steps before sending a referral. Incomplete referrals may be returned or declined.
  1. Referring providers must be an Allied Health Professional (OT, PT, SLP, Rec T).
  2. Read the Service Description and Eligibility Requirements to ensure your patient is appropriate for this service.
  3. Read the Referral Guidelines table below to find the reason why you are referring to this service.
  4. Click the (+) on the Referral Guidelines table below to ensure you the applicable required information and investigations to accompany the referral before submission. Review the applicable referral processes below and follow the instructions to submit the referral.
Urgent Referral Process
Urgent referrals are only accepted from acute care units.
Urgent referrals submitted by 1:00 pm on the same day of patient discharge will be triaged by the end of the business day. Urgent referrals submitted AFTER 1:00 pm on the same day of patient discharge will be triaged the next business day.
REFERRAL PROCESS - FOR CONNECT CARE USERS
Electronic referrals are made via Connect Care by submitting an External Order (Ref141 or Ambulatory Referral to Rehabilitation) using the following details:
  • By Provider: Name of referring provider
  • To Department Specialty: Rehabilitation
  • To Dept: CGY SMCC ESD
  • To Provider: leave blank (no information required)
  • Type: leave as Consultation
  • Priority: Routine
  • Reason (select one):
    • Rehab following stroke 
    • Rehab following non-traumatic brain injury
    • Rehab following traumatic brain injury 
    • Rehab following Spinal cord injury 
    • Rehab following Neurological Rehabilitation
Electronic referrals are made via Connect Care by submitting an External Order (Ref141 or Ambulatory Referral to Rehabilitation) using the following details:
  • By Provider: Name of referring provider
  • To Department Specialty: Rehabilitation
  • To Dept: CGY SMCC ESD
  • To Provider: leave blank (no information required)
  • Type: leave as Consultation
  • Priority: Routine
  • Reason (select one):
    • Rehab following stroke 
    • Rehab following non-traumatic brain injury
    • Rehab following traumatic brain injury 
    • Rehab following Spinal cord injury 
    • Rehab following Neurological Rehabilitation
ADDITIONAL SERVICE DETAILS
There is no physician on this service.  Patients are directed to their own family doctors, walk in clinic or AHS Health Link at 8-1-1.
There is no physician on this service.  Patients are directed to their own family doctors, walk in clinic or AHS Health Link at 8-1-1.
COMMUNICATION PROCESS
  • Referral receipt to referring source within 1 days.
  • Acceptance via appointment details or wait list status letter to referring source and patient within 5 days.
  • Appointment outcome to referral source within 5 days.
 
PHONE
403-955-6936 (switchboard)
FAX
403-476-4740
REFERRAL PHONE
403-955-6936 (Switchboard)
REFERRAL FAX
403-476-4740
REFERRAL FORM
Only a Connect Care referral order is accepted.
Only a Connect Care referral order is accepted.
LINKED SPECIALISTS
CLICK + TO VIEW REFERRAL GUIDELINES
+-
Routine Reason for Referral
Access Targets convey the clinically appropriate timeframe patients should be seen within, by reason for referral and priority level.
Access Target
Required Information/Investigations
Investigation Timing
Additional Details
+-
Neurological rehabilitation
Medication List (dose, frequency, route)
 
Within 1 month
Past medical history
 
Within 1 month
  • A routine referral from an acute care unit will be triaged within 24 hours of ESD Rehab Coordinator receiving the referral.
  • A routine referral from an inpatient rehab unit (i.e., FMC Tertiary Neuro Rehab Program or Dr. Vernon Fanning Neuro Rehab Program) will be triaged within 24-72 hours of ESD Rehab Coordinator receiving the referral.
PATIENT APPOINTMENT INFORMATION
Email
Print
 
MISSED APPOINTMENT GUIDELINES
Repeated appointment cancellations and/or no-shows may lead to ESD services being discontinued.
Repeated appointment cancellations and/or no-shows may lead to ESD services being discontinued.
 
HOURS OF OPERATION
Monday: 8:00 am - 4:15 pm
Tuesday: 8:00 am - 4:15 pm
Wednesday: 8:00 am - 4:15 pm
Thursday: 8:00 am - 4:15 pm
Friday: 8:00 am - 4:15 pm
   
 
ADDRESS
1213 4 Street SW
Calgary Alberta
T2R 0X7
PATIENT APPOINTMENT INSTRUCTIONS
  • Appointment bookings will be made by the team, with the patient, on a weekly basis.
  • For virtual appointments, patients should join the Zoom call 5 minutes before scheduled appointment.
  • Patients needing to cancel or reschedule appointments should do so by calling 403-955-6936.

NOTE: ESD services are not provided on weekends and statutory holidays.
  • Appointment bookings will be made by the team, with the patient, on a weekly basis.
  • For virtual appointments, patients should join the Zoom call 5 minutes before scheduled appointment.
  • Patients needing to cancel or reschedule appointments should do so by calling 403-955-6936.

NOTE: ESD services are not provided on weekends and statutory holidays.
 
DIRECTIONS
ESD services are provided in the patient’s home and community and/or by phone/virtual appointments.
ESD services are provided in the patient’s home and community and/or by phone/virtual appointments.
 
PHONE
403-955-6936 (switchboard)
 
PARKING INSTRUCTIONS
ESD services are provided in the patient’s home and community and/or by phone/virtual appointments.
ESD services are provided in the patient’s home and community and/or by phone/virtual appointments.
 
EMAIL
VIRTUAL APPOINTMENT INFORMATION
If patient has been booked for a virtual session, they will be notified by phone and/or email with the Zoom link.
If patient has been booked for a virtual session, they will be notified by phone and/or email with the Zoom link.
 
PARKING MAP
ESD services are provided in the patient’s home and community and/or by phone/virtual appointments.
ESD services are provided in the patient’s home and community and/or by phone/virtual appointments.
 
WHEELCHAIR ACCESSIBILITY
Yes

This facility is wheelchair accessible and has an elevator on site.


The primary purpose of the All Locations list is to let the user easily access any location of a healthcare service without going back to the main search screen.

The locations listed have 3 background colors:
  • Green means the healthcare service@location has referral information attached to it.
  • Brown means the healthcare service@location never had referral information attached to it, or it has unpublished referral information.
  • Red means
    • IA changed the healthcare service@location's status to something other than Current
    • It was deleted if it is an ARD healthcare service@location.
Green  and Brown are always at the top of the list. These are the Healthcare Service@Locations with the status of Current.
The Red list at the bottom consists of non-current Healthcare Service@locations that once had Published referral information in the ARD.
If the referral information was never published in ARD the Healthcare Service@location will not show in the Red list.

The secondary purpose of the All Locations list is to allow ARD Administrators to recover (copy) referral information from the non-current Healthcare Service@Locations to ones that are current.

Common Scenario:
A Healthcare Service moves from one location to another. In this case the IA Healthcare Service@Location record will be made defunct (non-current) and a new Healthcare Service@Location record will be created with a current status. In this scenario the captured referral guidelines in ARD can become "orphaned" as they are not attached to any current IA healthcare service.

Categories of non-current or orphaned referral guidelines: INDIVIDUAL and COMMON.
The REFERRAL GUIDELINES section of the profile has the prefix INDIVIDUAL or COMMON to help you choose the method below when transferring referral guidelines from a non-current Healthcare Service@Location to a current healthcare service@location.

Individual referral process
  1. Click on a non-current (Red) Healthcare Service@Location at the bottom of the All Locations list.
  2. The non-current referral info is displayed with the link Copy this Referral Process to another Healthcare Service@Location link on the upper right hand corner. Click on the copy link.
  3. Choose a current location (Green or Brown) from the All Locations list. This will be the Healthcare Service@Location you are pasting the referral info into.
  4. The system will display the Edit Referral Info screen populated with the referral info from the non-current Healthcare Service@Location you viewed in the first step.
  5. Click Save and the referral info is transferred from the non-current Healthcare Service@Location to the current one.
  6. Repeat these steps for each Healthcare Service@Location that needs attention.

Common referral process - 2 sub cases.
Case 1: At least 1 current Healthcare Service@Location with common referral info is with current status for this healthcare service; One or more Healthcare Healthcare Service@Locations where replaced by new one.
  1. Click on any current Healthcare Service@Location whether it has referral info (Green) or not (Brown).
  2. The healthcare service location opens in the Edit Referral Info screen populated with the current common referral info.
  3. Save it. 
  4. All locations will be updated with the common referral information, including all the locations that don't have referral info yet (Brown). The non-current referrals (Red) will also be updated.
Case 2:  All Healthcare Healthcare Service@Locations for a healthcare service are set to a non-current status and replaced by new ones. In this case there is no current additional referral info to copy from, so the only alternative is to pick up the non-current common referral process (Red). Follow the steps described in the section Individual Referral Process above to copy/paste the non-current common referral info to the current healthcare service locations.
Generally we want to replicate current common referral info to new or replaced healthcare service locations. We only resort to copying non-current common referral info if there is no other option.

Remember: Some fields can be location specific with the common referral process:
Parking Instructions, Directions, Parking Map, Wait Time, Referral Phone or Referral Fax.
To update these items you have to edit each Healthcare Service@Location separately.

ADDITONAL NOTES:
  • The info icon after the All Locations drop down will be visible to ARD Administrators.
  • The system doesn't allow you to copy referral information from one non-current Healthcare Service@Location to another.

 

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