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Early planning and teamwork key to supporting patients and families through discharge By Steph Parrott project spearheaded by an interdisciplinary team of staff on Mount Sinai Hospital’s Acute Care for Elders (ACE) Unit has led to a decrease in the number of alternate level of care (ALC) patients on the unit while providing patients and families with a more collaborative experience around planning for discharge and contributing to greater staff satisfaction. The ACE unit at Mount Sinai, part of Toronto’s Sinai Health System, specializes in caring for elderly patients – often with multiple co-morbidities – who require hospitalization for an acute condition. The unit’s interprofessional approach to meeting the unique needs of seniors has been held up as an example of a leading practice by Accreditation Canada. One of the challenges for the care team is in helping patients who no longer need the specialized acute care to successfully transition back into the community or into assisted living or long-term care. “This is a significant challenge for hospitals across the healthcare system as we adapt to an aging population of patients with increasingly complex care needs,” says Rebecca Ramsden, Nursing Unit Administrator on the ACE unit. “For this population of patients, a complex combination of social, functional and cognitive challenges put them at risk of having a prolonged hospital stay, beyond what is needed for their acute medical issue. Patients may also be at risk of poor outcomes post-discharge, leading to an emergency department visit or readmission to the hospital.” In the spring of 2016, the number of ALC patients at Mount Sinai’s ACE unit climbed to over half of the patients on the 28-bed unit. An interdisciplinary team took up the task of developing a strategy to help. “We recognized that in order to better serve our patients, both on


At a recent education event, Sabrina Gaon, Manager, Interprofessional Allied Health for Social Work and Clinical Nutrition (right) shares with colleagues about an initiative that decreased the number of ALC days on Mount Sinai Hospital’s Acute Care for Elders (ACE) unit.

ONE OF THE CHALLENGES FOR THE CARE TEAM IS IN HELPING PATIENTS WHO NO LONGER NEED THE SPECIALIZED ACUTE CARE TO SUCCESSFULLY TRANSITION BACK INTO THE COMMUNITY OR INTO ASSISTED LIVING OR LONG-TERM CARE the unit and those waiting for beds in the emergency department, we needed to re-consider how we plan support and engage with our most complex patients and their loved ones,” says Rebecca. The team conducted literature reviews, tested screening tools and ultimately developed the Transition Planning Risk Assessment Screen (T-PRAS) along with a robust transition planning process. Whenever the screening tool identified a patient as at-risk, the new transition planning process would be initiated. This process included social work notification of risk, a healthcare team meeting followed by a patient care meeting within five days of admission. Essen-

tial to a successful patient care meeting, the pre-meeting with members of the healthcare team ensures clarity and cohesiveness in the information to be provided to patients and their loved ones. “Bringing together staff members from all disciplines to contribute their expertise to address the individual needs of each patient was an important component of the process we developed,” says Sabrina Gaon, Manager, Interprofessional Allied Health for Social Work and Clinical Nutrition. “These meetings, held early on in the patient’s stay, have helped us work together collaboratively to find solutions for successful discharge with our patients and their families.”

Lydia Chan, a social worker on the unit, says this cohesive team approach helps everything run more smoothly and efficiently. “This has become a shared experience, with staff from all disciplines working together and understanding that we each have different perspectives and a different role to play. It also ensures we’re all on the same page in communicating with the family about the transition plan.” Patients and families have responded positively to the process and reported feeling engaged and supported. Sabrina attributes this to giving patients, families and the care team the opportunity to meet and talk about discharge soon after admission. “The patient and family meeting is a crucial part of the process that helps patients and families during what can be a difficult and stressful time. When patients and families see the whole care team is here for them they know that the lines of communication are open and the team is working together to meet their needs,” she says. “We can then have this important conversation where we help patients and families to understand the factors and options to consider as they are making decisions about discharge.” Since implementation in 2016, the unit has seen an increase in discharges, and fewer ALC days. The new transition planning approach has also had the benefit of improving staff satisfaction on the unit. “We conducted pre and post surveys of staff that showed a boost in morale with the implementation of this project. Staff are more satisfied knowing early on that there is a plan and process in place to support transition planning for the most complex patients,” says Rebecca. Positive outcomes of the pilot and months following supported the spread of the project to another medical unit. In the future the team expects the practice to be disseminated even further to other units across H Sinai Health System. ■

Steph Parrott is a Communications Specialist at Sinai Health System.


Hospital News 2018 March Edition  

Focus: Gerontology, Alternate Level of Care, Rehab & HSCN Conference. Special Wound Care Issue

Hospital News 2018 March Edition  

Focus: Gerontology, Alternate Level of Care, Rehab & HSCN Conference. Special Wound Care Issue