NEWS
Network strategy
leads to better patient care By Emily Dawson he family of an older woman who had fallen twice in relative short order at home brought her to the Emergency Department at St. Michael’s Hospital in downtown Toronto to see if there was some underlying health problem. A physician ran a battery of tests but found no sign she had suffered a stroke or other acute incident. Rather than admit her to the acute care hospital for further observation, the physician was able to transfer her directly to a more appropriate setting, Providence Healthcare, a rehab hospital, where she immediately began active therapy to regain mobility while being monitored in a safe environment. Previously, Providence would have been able to admit this patient only from a bed at St. Michael’s, meaning she would have moved from the ED to an inpatient unit to wait for referral. This process could take several days, delaying the start of active rehab. Thanks to a new patient access and flow strategy of the new network between Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s, teams on the ED of the two acute care hospitals can now liaise directly with Providence’s patient flow team to jump-start the process to bring them to Providence. “This is incredibly beneficial for our patients, because they’re receiving exactly the kind of care they need which means better health outcomes,” says Maggie Bruneau, vice-president, clinical programs and chief nursing executive. “On the hospital side, there are fewer inpatient admissions so we can concentrate on providing acute care to those who really need it.” In addition to the new admit from ED strategy, St. Michael’s and St. Joseph’s have processes in place to create more seamless transitions of care.
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Photo courtesy of Providence Healthcare
Getting an early start in active rehab can help seniors return home sooner and with better health outcomes.
ALC ROUNDS AT ST. MICHAEL’S Like most programs at St. Michael’s, General Internal Medicine has a lot to cover during its daily and weekly rounds. Many of its patients have complex and concurrent illnesses and some require continued care after they leave the hospital. So in addition to case managers, clinical leader managers and directors, the program’s weekly ALC rounds are attended by team members from partner hospitals and representatives of the Toronto Central Local Health Integration Network. The result has been improved communication and understanding between the program and its partners and a faster transition for patients who are ready to recover at home or elsewhere in the community. This collaboration helps ensure that patients transition safely with the support they require and also frees up beds for new patients.
“These meetings are very important because we are looking at each person as an individual and helping support what they need for their care,” says Leighanne MacKenzie, program director, Inner City Health. “Our goal is to help identify and then break through the barriers to get our patients to the level of care that meets their needs.”
EARLY DISCHARGE PLANNING AT ST. JOSEPH’S The healthiest place for most people to be is in their own home. That’s why as soon as patients are admitted to St. Joseph’s Health Centre, teams are planning for their discharge. The goal is to get them back to an environment where they’re comfortable and functional as quickly as possible. To help make that happen, an interprofessional team in the ED works with the medical team to help patients get the care they need and then plan their next steps. This team includes a
transition planner, occupational therapist and geriatric emergency medicine nurse. If a patient doesn’t need to be admitted, this means helping him or her be discharged straight from the ED. If the patient does require further care, the team starts planning where he or she will go after the hospital stay, even before the patient is admitted to the hospital. When a patient moves on to a unit, conversations about discharge happen with physicians, members of the patient’s care team and their family so everyone is aware of the plan and can help provide support. “Helping patients move to the appropriate level of care is one of the ways we support our patients and their families,” says Dr. Peter Nord, vice-president, clinical programs and chief medical officer. “We’re excited to be able to work closely with our Network partners to leverage each others’ unique skill sets which ultimately benefits those who come to us H for care.” ■
Emily Dawson is a senior communications adviser at Providence Healthcare. 34 HOSPITAL NEWS MARCH 2018
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