By: Dana Corsi (Regional Rehab and ALC Lead), Melanie Briscoe and Dr. Jo-Anne Clarke, on behalf of the North East Regional Geriatric Program, North East Specialized Geriatric Centre (NESGC)  

When we talk about improving access to rehabilitative care, the conversation often starts with beds: Do we have enough? Who is waiting? How can people move sooner? These are important questions, but for older adults living with frailty, the story begins much earlier. 

Even a short hospital stay can change the course of an older adult's recovery. Acute illness, reduced mobility and an unfamiliar environment can quickly contribute to delirium, functional decline and loss of independence. Evidence tells us that if we wait until an older adult is ready to leave acute care before considering rehabilitative care, we have waited too long. Opportunities to maintain function, prevent avoidable decline and support recovery may already have been lost. 

The North East Regional Geriatric Program (NE RGP) at North East Specialized Geriatric Centre (NESGC) began asking how to recognize and address those needs earlier. Ideally, changes in function and rehabilitative care needs are identified and addressed in the community before hospital care is required. When an older adult is admitted, rehabilitative care cannot wait for referral to a rehabilitation bed. At a minimum, early identification of baseline function, restorative potential and cognitive and functional risks should begin in the emergency department. Medical management and functional optimization must then happen together throughout the hospital stay. 

Alternate level of care (ALC) and conservable bed days (CBD) can identify care journeys that warrant a closer look. ALC signals delays after a person no longer requires their current level of care; CBD points to stays beyond the expected length of stay. Both are useful signals, but neither explains why a delay occurred or what needs to change. That requires looking at the person, the full journey and the system expected to meet their needs.  

As a foundation, partners across the North East mapped rehabilitative care services for all populations against the Rehabilitative Care Alliance’s (RCA) provincial standards for bedded and community-based rehabilitative care. This went beyond counting beds or programs, showing what each service was equipped to provide: its intended population, functional focus, clinical resources and intensity of care. Communities used this work to develop locally adapted RCA referral decision trees, pathways matching a person's needs to service capability, and multi-year action plans. Testing pathway guidance with frontline providers also helped identify needs that did not fit existing services and where gaps remained. 

Building on this all-population foundation, the NESGC Implementation Playbook gave us a practical way to focus specifically on rehabilitative care for older adults living with or at risk of frailty. Local teams brought together population and care-trajectory data, local experience and an understanding of the existing service landscape. 

Photo caption: The NESGC Implementation Playbook applied to rehabilitative care for older adults living with frailty. 

Together, using the ALC Leading Practices Guide and the provincial best-practice framework for rehabilitative care for older adults living with frailty, we looked at the journey across community, emergency, acute and post-acute care. We asked when frailty and baseline function were identified, how restorative potential was assessed, what mattered most to the person, what was being done to prevent delirium and functional decline, and whether people could access the rehabilitative care that best matched their needs. 

This work has begun to produce meaningful changes in systems and practice. Communities have a clearer, shared understanding of their rehabilitative care capacity and where it does not match the needs of older adults living with frailty. Practical changes include early identification tools and processes in the emergency department; strengthening interprofessional rounds in acute care so that baseline function is understood and rehabilitative care and transition needs are addressed earlier and more consistently; and education about local rehabilitation programs and how to determine restorative potential. 

What have we learned? Rehabilitative care needs to be part of the standard of care throughout hospitalization, not something that begins when medical treatment ends. For other health system partners, the lesson is not that every community needs the same pathway or program. It is that improvement should begin with the population, not the indicator. ALC and CBD can show us where to look; understanding the older adult's journey and the system's actual capabilities tells us what needs to change. 

Success is not simply moving an older adult through hospital more quickly. It is making sure that care at every stage protects function, supports recovery and leads toward the right next setting. For older adults living with frailty, rehabilitative care starts long before the rehabilitation bed. ​