Collaborative Care Transitions Symposium brochure

Collaborative Care Transitions Symposium FEBRUARY 19, 2016

The College of Family Physicians of Canada This program meets the accreditation criteria of The College of Family Physicians of Canada and has been accredited by Continuing Professional Development, Faculty of Medicine, University of Toronto, for up to 6.0 Mainpro-M1 credits.

Royal College of Physicians and Surgeons of Canada – Section 1 This event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada, approved by Continuing Professional Development, Faculty of Medicine, University of Toronto, up to a maximum of 6.0 hours.

Contents Message from Conference Leads

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Agenda

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Collaborative Care Transitions Symposium Themes

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Keynote Speaker

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Patient and Family Panel

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Workshop Descriptions

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Oral Presenter Abstracts

Concurrent Session 1

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Concurrent Session 2

15

Concurrent Session 3

18

Concurrent Session 4

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Concurrent Session 5

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Concurrent Session 6

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Poster Presentations (Listed by Themes and Abstract ID)

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Poster Presentations Map (Grouped by Themes and Abstract ID)

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Location 39 Acknowledgements 40

Collaborative Care Transitions Symposium

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Message from Conference Planning Committee The Collaborative Care Transitions Symposium is a 1-day event focusing on topics that are relevant to those involved in the patient and family care transition journey along the continuum of care. The symposium, through informative and interactive sessions and posters, will highlight the innovative ideas of clinicians, researchers, educators, and quality improvement leaders that aim to improve the transitional care experiences of patients, family caregivers, and health care professionals. The symposium will also feature leading edge research presented by our keynote speaker and valuable insights from our patient panel.

Conference Leads: Beverly Bulmer, Director, Health Discipline Practice and Education Aimee Hindle, Manager, Health Disciplines and Academic Affairs, Professional Practice Lianne Jeffs, St. Michael’s Hospital Volunteer Association Chair in Nursing Research and Director of Nursing Research Murray Krock, Director, Nursing Practice and Education Colleen McNamee, Corporate Nursing Education Leader, Nursing Practice and Education Kaleil Mitchell, Project Coordinator, Nursing Practice and Education Noor Ramji, Family Physician, Quality Improvement Lead, Academic Family Health Team Cecilia Santiago, Manager, Nursing Practice, Nursing Practice and Education Marianne Saragosa, Research Coordinator, Nursing/ Clinical Research Vicky Stergiopoulos, Psychiatrist-in-Chief, Mental Health Services

Executive Support: Ella Ferris, Executive Vice President, Programs, Chief Nursing Executive and Chief Health Discipline Executive, St. Michael’s Hospital

Program Objectives

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To provide a platform to share new/recent quality improvement and research on transitions in care

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To foster discussion about transitions in patient care and provide participants with networking opportunities

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To identify and discuss key issues in engaging patients and families about transitions through the continuum of care

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To share innovative approaches addressing transitions in care

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To explore collaborative approaches and insights on the lived experience of care transitions about care

St. Michael’s Hospital

TIME 0800-0830

AGENDA

LOCATION

Registration

LKSKI 2nd floor

Continental breakfast

Exhibition Space LKSKI Allan Waters Auditorium

0830-0845

Opening Remarks Dr. Robert Howard, President & CEO, St. Michael’s Hospital Ella Ferris, Executive Vice President, Programs, Chief Nursing Executive and Chief Health Discipline Executive, St. Michael’s Hospital

LKSKI Allan Waters Auditorium

0845-0930

Keynote Address Paul Stolee, PhD, University Of Waterloo, Waterloo, Ontario

LKSKI Allan Waters Auditorium

0930-0945

0945-1115

1115-1200 1200-1245 1245-1400 1400-1415

1415-1545

1545-1600

Travel time Workshop 1: Patient and Family Engagement

LKSKI Room 136

Workshop 2: When Push Comes to Shove: Advancing Collaborative Communication and Collegial Relationship

LKSKI Room 240

Concurrent Session 1 (Oral presentations): Patients with Complex Care and Social Needs

LKSKI Room 211

Concurrent Session 2 (Oral presentations): New and Emerging Models of Collaborative Care Focusing on all Transition Points

LKSKI Allan Waters Auditorium

Concurrent Session 3 (Oral presentations): Experiences and Perceptions of Patients, Families and Providers Toward Care Transitions

LKSKI 216

Poster Presentations and Viewing

LKSKI 2nd floor Exhibition Space

Lunch Patient and Family Member Panel

LKSKI Allan Waters Auditorium

Travel time Workshop 1: Patient and Family Engagement (repeated)

LKSKI Room 136

Workshop 2: When Push Comes to Shove: Advancing Collaborative Communication and Collegial Relationship (repeated)

LKSKI Room 240

Concurrent Session 4 (Oral presentations): Patients with Complex Care and Social Needs

LKSKI Room 211

Concurrent Session 5 (Oral presentations): New and Emerging Models of Collaborative Care Focusing on all Transition Points

LKSKI Allan Waters Auditorium

Concurrent Session 6 (Oral Presentations): Experiences and Perceptions of Patients, Families and Providers Toward Care Transitions

LKSKI 216

Announcement of Poster Winners: Best Research Poster and Best Quality Improvement Poster & Closing Remarks

LKSKI Allan Waters Auditorium

Collaborative Care Transitions Symposium Themes Patients with Complex Care and Social Needs This theme will address the distinctive care transition needs of patients who may have complex care needs requiring specialized knowledge and expertise and/or social needs that are typically considered beyond the traditional purview of the health care system. Such needs may include housing, social support, addictions and/or mental health concerns, low income, literacy or others. Examples of topics within this theme include: • • • • •

Challenges in care transitions Issues of equity and marginalization Transitioning to rural and remote communities Care transitions for patients with multiple co-morbidities Patient engagement

New and Emerging Models of Collaborative Care Focusing on all Transition Points Within this theme presenters will share innovative models of care that incorporate a collaborative teambased approach to supporting patients and families through care transitions. Well-coordinated sharing of vital patient information within the care team is central to optimize the quality of care transitions for patients and families along the trajectory of care. Examples of topics within this theme include: • • • •

Innovative models of discharge planning Links to community and primary care providers Reducing re-admission rates Collaborative care

Experiences and Perceptions of Patients, Families and Providers Toward Care Transitions Presenters will showcase research studies and innovative initiatives that explore the experiences and perceptions of patients, families and health care providers towards care transitions. Understanding the experiences and perceptions of those directly involved in care transitions is critical for informing the continuous improvement of transitions along the continuum of care. Examples of topics within this theme include: • • • • 6

The lived experience of patients and families Patient engagement strategies Engaging frontline clinicians in care transitions Patient safety

St. Michael’s Hospital

Keynote Speaker

Paul Stolee, PhD

Dr. Paul Stolee is an Associate Professor in the School of Public Health and Health Systems, University of Waterloo. He obtained his PhD in Health Studies at the University of Waterloo, after completing an MSc in Clinical Epidemiology and Biostatistics at McMaster University, a Master of Public Administration degree at Queen’s University, and an undergraduate degree in Political Science at the University of Alberta. Dr. Stolee’s research focuses on strategies to improve the quality of life of older persons, and to improve the effectiveness of geriatric health services. For the past several years, Dr. Stolee’s CIHR-funded research program “InfoRehab” has investigated the use and sharing of health information for older persons with chronic illness. This work has led to an increased interest in the challenges experienced by older patients as they transition across care settings, and on strategies that can foster greater health system integration. Dr. Stolee is overseeing several projects for one of Canada’s Networks of Centres of Excellence, AGE-WELL - Aging Gracefully across Environments using Technology to Support Wellness, Engagement and Long Life.

AGE-WELL aims to harness and develop policies and advanced technologies to support health and independence of older persons.

Dr. Stolee is actively involved in research on how knowledge is translated into practice and policy, and is concerned in his own research with the meaningful engagement of stakeholders in all stages of the research process. A current focus of his research is on strategies to engage seniors in health care decision-making and research. His team’s research is supported by the SHARP group – Seniors Helping as Research Partners (https://uwaterloo.ca/geriatric-health-systems-research-group/sharp).

Dr. Stolee is the 2012 recipient of the Canadian Association on Gerontology Evelyn Shapiro Mentoring Award. He has published over 130 peer-reviewed manuscripts and seven book chapters, and is the current Editor-in-Chief of the Canadian Journal on Aging.

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Patient and Family Member Panel It is the goal of health care providers to ensure patients and their family and informal caregivers experience safe and effective transitions in care. However, according to the literature, research, and personal narratives, failures in transitions of care often occur. Through the panel discussion, former patients, service users, and family members will share their personal experiences and reflections on transitions across care settings. There will be opportunity to discuss the impact of care in transitions including: contributing factors in failed transitions; opportunities to provide quality transitional care; and how to collaborate with patients and facilies.

During the Patient and Family Member Panel, you will have an opportunity to learn from the following panel members: Gord Singer has been the Peer Support Specialist at FOCUS Community Mental Health and Addictions, St. Michael’s since 1999. Gord has accessed psychiatric services in Toronto since 1975.

Gord received the ‘Courage to Come Back’ award in 1999 and a ‘Values in Action Award’ from St. Michael’s in 2009. Gord has published 2 articles on recovery and is a member of Mensa.

Sarah-Lyn Copeland is 20 years old and living with cystic fibrosis. She grew up going in and out of Sick Kids Hospital to fight off lung infections. Two weeks before her 18th birthday, she received a double lung transplant at Sick Kids Hospital. Thereafter, Sarah-Lyn transitioned from Sick Kids to St. Michael’s Hospital, Toronto General Hospital, and Princess Margret Hospital. Sarah-Lyn and her mother, Jacqueline Copeland, are here today to talk about their transition from pediatrics to adult care.

Jacqueline Copeland is the mother of Sarah Lyn. As parents of a child born with cystic fibrosis, Jacqueline and her husband’s journey at Sick Kids started on October 21, 1995 and ended on October 21, 2013 when Sarah-Lyn turned 18 and received a double lung transplant. The Copeland family transitioned from one hospital, that took care of everything, to three new hospitals (St. Michael’s Hospital, Toronto General Hospital, and Princess Margaret). Being used to going to a single hospital that took care of everything, they are now in the process of getting to know the various healthcare providers from each of the three hospitals. Jacqueline describes the transition as “overwhelming, to say the least.”

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St. Michael’s Hospital

Workshops Patient and Family Engagement Worksop Facilitators: Jacobi Elliott, PhD (Cand.); Heather McNeil, PhD (Cand.)

Capacity: 25-30 participants maximum Workshop description: Patient and family engagement has been recognized as an important component of health system improvement and has been linked with improved patient outcomes.

While this topic has been popularized in the literature and many health care systems are working to implement engagement strategies, many questions remain about how best to engage patients and families. The Geriatric Health Systems (GHS) research group, led by Dr. Paul Stolee (University of Waterloo) has been extensively working to understand best practices in the area of patient and family engagement. Through a realist synthesis (Stolee et al., 2015) frameworks and strategies for engaging patients and families in health care research, planning, and clinical decision-making were identified.

Results from this project, as well as the GHS groups’ specific engagement experiences will be shared in this workshop. Participants will have an opportunity to hear directly from patients as well as be engaged in participatory methods to develop practical skills for engaging patients and families across the health care continuum.

Participants will have an opportunity to: •

Be able to describe the value and importance of patient and family engagement in health care research, planning, and clinical decision-making

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Have an understanding of patient and family engagement frameworks that can be used to guide real world engagement

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Have experience working with an engagement toolkit of strategies and principles to use in their health care work

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Be aware of challenges and opportunities in engaging patients and families

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Have an opportunity to discuss their experiences with patient and family engagement with others working across the health care continuum

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When Push Comes to Shove: Advancing Collaborative Communication and Collegial Relationships Workshop Facilitators: Kerry Knickle LLM (ADR); Nancy McNaughton MEd, PhD Capacity: 25-30 participants maximum Workshop description: Challenging communication with colleagues can be a significant source of stress, consume considerable time and negatively impact our patients and health care teams. These conversations can also be an opportunity for change, improved collegial relationships and fresh perspective. We tend to be better in difficult conversations with our students and patients than we are with our peers which can feel slightly risky for many reasons. Health professionals require a toolbox of communication skills and abilities that incorporate a high degree of integration and awareness in order to navigate the personal and professional environment. Gaining this dexterity requires professional development and conflict resolution skills that can enhance collaborative team function.

This 90 minute workshop is an introduction to those interested in best practices skill development in conflict resolution and its role in team function. Using attribution theory as a theoretical frame, participants are able to explore practical communication strategies to manage conflict and collegial tension. Live simulation will stimulate discussion and shared problem- solving around challenging team encounters.

Participants will have an opportunity to:

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Reflect on one’s own response to conflict.

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Examine the personal and professional issues that arise in the simulated encounter.

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Acquire a greater theoretical and practical understanding about the judgments and assumptions made in the workplace

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Analyze “wicked” communication triggers within a team context

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Review and practical effective communication responses in challenging situations

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Participate in group problem solving and debrief of a simulated encounter.

St. Michael’s Hospital

Oral Presentation Abstracts Concurrent Session 1 Patients with Complex Care and Social Needs PRESENTATION 1 ID. 69 Prompt and Sustained Primary Care Contact as Care Transition Priority Agnes Kulinek Toronto Western Hospital Background: Two thirds of the health care system is utilized by 5% of the population living with multiple complex medical conditions requiring intensive, well-coordinated care. To achieve this a single point of contact with a primary care provider (PCP), to address the patient’s complex healthcare needs, is required.

Objectives: The Transitional Care Specialist (TCS) role at Toronto Western Hospital was implemented as a one year trial role in July 2014 to promote smooth care transitions for complex Medicine patients returning home in an effort to reduce avoidable readmissions. Arranging an appropriate PCP for unattached patients and encouraging their 7 day post discharge contact is an active priority of the TCS role. The goal is that 100% of patients have an appropriate PCP pre discharge and for 80% to have ongoing contact with this provider for up to 3 months post discharge.

Methods: The TCS explores each individual patient’s needs and level of care required to make relevant connections with appropriate contacts for primary care. To promote contact with primary care post discharge, several steps are put in place such as booking appointment pre discharge and inclusion of details in discharge summary. Attendance is encouraged in TCS post discharge follow up calls.

Results: In the first year of the TCS role, 96% (74/77) of unattached patients were connected with a PCP. In a random sample of newly attached patients, it was found that 57% (13/23) of patients saw their PCP within 7 days. At 1 month post discharge, 78% (18/23) of these patients had contact with the PCP. At 2 and 3 months, 57% (13/23) of patients had continued to see their arranged PCP. Conclusions: The results suggest that the TCS in the acute care setting is successful at connecting complex patients with an appropriate PCP and can be utilized elsewhere. Further investigation is required to identify why some patients did not sustain contact with a newly attached PCP.

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PRESENTATION 2 ID. 88 Identifying Effective Nurse-Led Care Transition Interventions for Complex Older Adults Using a Structured Expert Panel Lianne Jeffs, Sharon Straus, Monika Kastner, St. Michael’s Hospital/Li Ka Shing Knowledge Institute; Vera Nincic, Maria Maione, Marianne Saragosa, Ella Ferris, St. Michael’s Hospital; Madelyn Law, Brock University; Kerry Kuluski, Lunenfeld-Tanenbaum Research Institute;Sherry Espin, Ryerson University; Chaim Bell, Jane Merkley, Sinai Health System; Brenda Dusek, formerly with the Registered Nurses’ Association of Ontario Background: Poorly executed care transitions involving older patients with complex care needs results in medication errors, care delays, avoidable re-admissions, and increased healthcare costs. Nursing plays a central role to facilitating care transitions for complex older adults, however there is no expert consensus of the components of nurse-led care transitions interventions among complex older adults.

Objective: To address the aforementioned gap, a project was undertaken to delineate from the evidence and expert opinion on the optimal nurse-led care transitions.

Methods: This project involved a realist review of the literature and a modified Delphi panel. Panelists (n=23) part of the Delphi panel were asked to individually rate a series of statements derived from the literature for relevance, feasibility and likely impact. Statements receiving an aggregate score of ≥75% (7/9) were then reviewed and revised at a face-to-face consensus meeting. A second round of rating following the same process as round 1 was used, followed by a final ranking of the statements.

Results: As part of the Delphi panel results, the five highest ranked intervention components and contextual factors were: 1) educating and coaching patients, their family members, and/or their care givers about self-management skills; 2) ensuring patients, their family members and/or caregivers are aware of follow-up medical appointments and post-discharge care plan; 3) using standardized documentation tools and comprehensive communication strategies during care transitions; 4) optimizing nurses’ roles and scopes of practice across the care transitions spectrum; and 5) having strong leadership, strategic alignment and accountability structures in organizations to enable quality care transitions for the complex older person population.

Conclusions: Key insights on optimizing the nurses’ roles and scope of practice during care transitions included having nurses provide “warm hand-offs” and serve as the “go-to person”. The panel identified current challenges to fully optimizing the nurses’ roles and scope of practice across care transition points. Future research is required to determine the optimal components of nurse-led intervention, and in which context do they work or do not.

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St. Michael’s Hospital

PRESENTATION 3 ID. 96 Mind the Gap: Improving the Post Discharge Transition to Reduce Rapid Psychiatric Readmissions Tara Burra, Gwen Yorston St. Joseph’s Health Centre Background: Rapid psychiatric readmissions stem from a complex interplay between hospital, community, health care provider, and patient factors. Readmission within 30-days of a psychiatric hospitalization is a quality of care indicator that assesses both inpatient care and continuity of care in the community. Over the past decade, St Joseph’s Health Centre (SJHC) has had one of the highest psychiatric readmission rates in Ontario. Early readmission represents an opportunity for improving access and integration of inpatient with ambulatory care.

Objective: To enhance access to timely ambulatory psychiatric care at SJHC and improve patients’ post-discharge transition to achieve the broader goal of reduced psychiatric readmissions.

Method: Ambulatory psychiatric services were restructured in 2012 to create the Collaborative Care Clinic (CCC), a team-based, inter-professional approach to patient care. An open-access online appointment scheduler was implemented. Using the Model for Improvement, we introduced the following initiatives: updating patient contact information before discharge, standardizing appointment reminder phonecalls, and implementing patient experience questionnaires. Outcome measures include attendance of the initial post-discharge ambulatory appointment, timeliness of postdischarge appointments, and readmissions within 30 days.

Results: Over 400 post-discharge ambulatory appointments were scheduled for discharged inpatients in 2013 and 2014. In 2013, 63% of patients attended their initial appointment and 78% of the appointments were scheduled within 4 weeks of discharge. In 2014, 73% of patients attended their initial post-discharge appointment and 82% were scheduled within 4 weeks of discharge. The rate of 30-day readmission to SJHC for patients who attended CCC was 4.8% and 17.5% for those who were not referred to the clinic.

Conclusions: We have implemented and sustained an open-access online appointment scheduler.

Despite greatly enhancing the availability of appointments, non-attendance remains a concern, and we will continue to implement strategies, guided by patient feedback, to improve the post-discharge care transition. We have preliminary evidence to suggest that the CCC model is reducing psychiatric readmissions; however, data on 30-day readmissions to other institutions, following an index hospitalization at SJHC, is not yet available to inform our evaluation.

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PRESENTATION 4 ID. 130 Smooth Transitions: Importance of Self-management for Cystic Fibrosis Patients Moving from Paediatric to Adult Care Susan Carpenter, Kate Gent Hospital for Sick Children, St. Michael's Hospital Background: The median age of people living with Cystic Fibrosis (CF) is now over 50 years of age.

Literature on transition in chronic illness demonstrates the need to provide education at appropriate stages of development to enable young patients to become self-care agents. Newly transitioned patients express frustration and lack of preparation to become independent in their health management. This leads to gaps between individual patient preparedness and health care provider expectations, which impacts ability for patients to self-manage their care.

Objective(s): To improve CF patients’ readiness to succeed in transitioning from paediatric to adult CF care.

Methods: Review of the CF Toronto database and the current transition program provides a background knowledge of our patient population. To assess individual patient readiness, a validated tool (TRAQ) was completed by paediatric patients aged 14 to 17 (n=10) and adult patients aged 17-20 (n=10). Results show gaps in preparedness to transition.

Results: Statistical analysis of the TRAQ questionnaires highlights that young adults are not aware of how they can obtain financial assistance or the importance of asking questions at their clinic visits.

Paediatric patients are unfamiliar with their drug coverage, how to make appointments and refill medications. To address knowledge gaps, further patient education in both paediatric and adult CF centres is necessary.

Conclusions: Although we have a well established transition program for patients with CF in Toronto, a detailed assessment has lead us to recognize shortcomings of paediatric patient preparedness prior to transition and their experience of being overwhelmed when joining the adult program. Future directions include the paediatric team addressing education needs and learning gaps throughout each development stage to encourage independence prior to transitioning to adult care. Adult team members can provide adult education and work with patients and families to promote independence and self-care. This joint assessment has confirmed the importance of good communication between paediatric and adult teams to achieve successful outcomes in transition from paediatric to adult CF care.

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St. Michael’s Hospital

Oral Presentation Abstracts Concurrent Session 2 New and Emerging Models of Collaborative Care Focusing on all Transition Points PRESENTATION 1 ID. 38 Toronto East General Hospital and Toronto Central CCAC: Partners in Alternative Level of Care Transitions Lindsay Martinek, Debbie Guyader Toronto East General Hospital, Toronto Central CCAC Background: TEGH had one of the highest numbers of ALC patients in the TCLHIN. ALC transitions require strong relationships and significant partnerships to successfully discharge patients. The redesign of the ALC Huddle was needed to increase collaboration and communication, decrease ALC days and time to discharge.

Objectives: The redesign was intended to: improve flow/bed capacity and reduce ALC and LOS; improve communication, collaboration and coordination of care between patient/family, hospital, CCAC and community partners; create a safe forum for discussion; build capacity through knowledge sharing, and identify and escalate the most challenging patient scenarios to senior leadership.

Method: Focus groups were conducted with front line staff, care coordinators, TEGH and CCAC leadership and physicians. The focus groups provided information about current challenges and areas of dissatisfaction. The team worked through a change management process to identify improvement strategies The huddle provided a forum for front line staff and leadership from both TEGH and CCAC to discuss barriers to discharge and action plans required to transition ALC patients. We conduct two huddles per week. The first identifies patients “at risk for delay” or “delayed” discharge, barriers to discharge, and action plans. Discussion about the challenging and complex patients in the first huddle guides the discussion for the second huddle of the week. The second huddle is attended by key decision makers such as clinical managers, directors and executive leadership from both TEGH and CCAC. Result: The huddle evolved into a forum of mutual respect, collaboration, coordination and problem solving. It strengthened the relationship between the hospital and CCAC as well as created a renewed commitment to working as a team. The initiative has been sustained and and has improved the experience of ALC patients and their families.

Conclusions: Since the implementation of the new huddle format, TEGH has seen a decrease in ALC days every quarter of 2014. Patients waiting for LTC at TEGH has steadily declined.

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PRESENTATION 2 ID. 87 Knowing Each Other’s Work: Evaluating the Impact of Essential Professional Conversations on Care Collaboration at Times of Transition and Gaining Insights for Sustainability Sherry Darling, Sylvia Quant, Gail Avinoam, Shelley Sharp, Beth Linkewich, Jacqueline Willems, Cate Creede - Toronto West Stroke Network, North East GTA Stroke Network, South East GTA Stroke Network, The Potential Group Background: Stakeholders within the Toronto Stroke Networks (TSNs) identified the time of patient transition as an opportunity to significantly impact quality of care for people with stroke (PWS). Stronger relationships between Health Care Providers (HCP) across the system can optimize transitions for PWS. A multipronged project, Knowing Each Other’s Work (KEOW), was implemented within the TSNs to foster learning, curiosity and meaningful collaboration between HCPs. We developed two initiatives: Essential Professional Conversations for Seamless Care (EPC) and Stroke Care Observerships (SCO).

Objectives: 1) To evaluate the impact of EPCs when used by HCPs at the time transition, and 2) to gain insight on strategies to sustain this initiative.

Methods: Nine semi-structured interviews were conducted with HCPs in 3 hospitals that were early adopters of EPCs. The EPC toolkit included education, practice enablers and reflective tools to facilitate dialogue and collaboration between acute care and inpatient rehabilitation. Participants shared stories of their experiences.

Results: Thematic analysis revealed increasing efficiency and effectiveness of care delivery, as well as improved relationships, trust and confidence between HCPs. Particularly meaningful were themes that emerged around the importance of explicit attention to the elements of the toolkit to ensure success.

Identified key enablers included a reliable method of contacting HCPs, use of practice enablers such as the EPC pocket card that included strategies to engage generative conversations, and dedicated time to reflect and share about their experiences.

Conclusions: EPCs offer optimal opportunities to foster learning, curiosity and meaningful collaboration between HCPs across the care continuum. Insights for enhancing sustainability include use of a train the trainer model, integration of EPCs into usual practice, and ongoing support for champions through a community of practice. All elements of EPC are essential and may have a broader application across chronic disease populations where patient complexity requires a collaborative approach to care.

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St. Michael’s Hospital

PRESENTATION 3 ID. 94 An Innovative Model of Care and Electronic Solution to Engage Clinicians in Facilitating Testicular and Endometrial Cancer Patients Transition to PostTreatment Survivorship Doris Howell, Sarah Ferguson, Padraig Warde, Menaka Pulandiran, Beth Edwards, Jennifer M. Jones University of Health Network, Princess Margaret Cancer Centre Background: Cancer survivors’ experiences from their disease and treatments have impact on their long term quality of life. Transitions from active treatment to post-treatment survivorship is described as highly distressing. Transition appointments and Survivorship Care Plans (SCPs) are proposed as a solution but are not yet implemented as a standard of care in ambulatory cancer care. We developed a model of care inclusive of transition appointments, electronic SCP, and clinician training. In this paper, we highlight the transition model of care and lessons learned in implementation.

Objectives: 1) To assess enablers/barriers to uptake of transition care process and SCP, 2) to develop a model of care tailored to the disease sites and resources, 3) to use multifaceted strategies to facilitate implementation in routine care, and 4) to evaluate uptake on process evaluation metrics and patient outcomes.

Methods: This knowledge translation study used a pre-post, multi-method (quantitative and qualitative) research design. A population cohort of testicular and endometrial cancer patients completed surveys pre and post implementation. A participatory action and knowledge translation process were used do faciltate practice change. A Delphi process was used to engage clinicians in designing a tailored SCP and model of care for implementation. Descriptive and correlation statistics were used to summarize quantitative survey data from patients. Clinicians and patients participated in qualitative interviews that were analyzed for themes based on the tenets of grounded theory.

Results: Clinicians and patients both valued the provision of a comprehensive SCP that included surveillance procedures, late and long term effects and management, and secondary health promotion and risk prevention. Pre-implementation data revealed cancer patients experienced health distress pre-implementation and preliminary analysis of post-data findings suggest patients who received a SCP and transition appointment experienced less distress and felt more prepared for post-treatment survivorship.

Conclusions: Implementation of practice change in high volume ambulatory cancer care requires attention to numerous logistical challenges to sustain long term change.

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Oral Presentation Abstracts Concurrent Session 3 Experiences and Perceptions of Patients, Families and Providers Toward Care Transitions PRESENTATION 1 ID. 50 Improving Transitions in a Post Acute/Sub Acute Healthcare Environment through Engagement, Partnership and Co-design with Patients and Families Sandra Schmidt, Beverley Shea, Christine Maika, Debbie Gravelle, John Robinson, Jacqueline Tetroe, Maria Judd Bruyere - Continuing Care, Bruyere Research Institute, Canadian Foundation for Healthcare Improvement Background: In the past 5 years, the population admitted to a CCC has changed dramatically with patients are arriving from acute care sooner and sicker. The average LOS in the previous 2 years has decreased to less than 75 days. Transforming our care provided an opportunity to work with our patients/families to co-design processes and conduct quality improvement projects. We partnered with the Bruyère Research Institute and the Canadian Foundation for Health Care Improvement to develop our Patient/Family Advisory Committee and to transform our patient care experience at transitions and at the bedside.

Objectives: To partner and codesign quality initiatives with our patients/families to enhance lives and transform care.

Methods: Solution focused concept mapping exercise was undertaken. Patient stories were captured and analyzed. Kaizen events focused on transitions. Skill mix was adjusted to provide increased professional care for our complex patient population. Mandatory professional education was provided for all nursing staff in 5 key areas: Adopting “Always Practices” Customized Care Boards; Volunteers Ambassador Program; Patient and Family Advisory Committee; Path to Home Discharge Passport, and “Path to Home Resource Lounge.”

Results: Very positive experience patient and family outcomes have come directly from partnering with patients/families to co-design multiple quality improvement initiatives. Admissions now have nonclinical questions answered and tours of their new environment. The customization of care boards and co-design process with the patients/families provide information they identified as essential and a method for 2-way communication.

Conclusions: Hearing patient/family stories about their experience provided a call to action. Supportive project sponsor and senior leadership are essential for success. Embedding patient and family codesign into existing processes and leveraging quality improvement teams are essential for sustainability and ongoing improvement Partnering with the Bruyere Research Institute and the Canadian Foundation for Healthcare Improvement has accelerated quality improvement processes and outcomes. Patients and families are thrilled to be part of the improvement processes and see intiatives from start to finish.

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St. Michael’s Hospital

PRESENTATION 2 ID. 58 Learning With and From One Another; Patients and Providers on the Same Improvement Path Valentina Constantinescu St. Joseph's Healthcare Hamilton Background: St. Joseph’s Healthcare Hamilton (SJHH) has been on a journey to partner with patients and families for a number of years, but in the last five years has begun formalizing and accelerating this work. An evidence based approach was used to improve the discharge process for patients on a Medical Rehabilitation unit at SJHH. This project was inspired from information collected during a series of patient shadowing activities, discharge surveys, and staff feedback. There were two themes highlighted by patients from these activities: feeling overwhelmed on discharge day and a willingness to be more engaged in their discharge process.

Objectives: To enhance patient, family, and staff experience in the discharge process.

Method: We partnered with patients/families to co-design, develop, implement, and develop a sustainable plan for the change in practice. The Plan-Do-Study-Act (PDSA) improvement model guided us through developing, testing, and implementing changes leading to improvement. The staff and patients worked together to: develop an education package for patients/families that reflect patients/ families priorities for discharge; engage all patients and families in the discharge process by using the teach back methodology; develop documentation to support staff practice, and improve the education package using information from: patient survey, follow up calls post discharge and debriefing with staff and patients/families.

Results: Preliminary results show significant improvement on family involvement in the care and decisions and on information provided around medication and medication management.

Conclusions: This improvement project engaged patients and families directly in the design, implementation and evaluation of the discharge process. Education is now provided on the unit every day when required and learning needs are assessed at each interaction. Now, patients and families are receiving the information they want, when they need it, and in a way that they can understand.

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PRESENTATION 3 ID. 165 Enhancing the Patient Experience through Standardized Nurse-to-nurse Intershift Bedside Transfer of Accountability Cecilia Santiago, Murray Krock, Lianne Jeffs, Ella Ferris St. Michael's Hospital Background: Nurses have historically provided intershift transfer of accountability (ToA) at the nursing station. Since ToA was conducted away from the bedside, patients and families were not involved in care planning during shift change.

Objectives: To describe the process of implementing, evaluating and sustaining a standardized nurse-to-nurse intershift bedside ToA process, and to elicit patient and family perceptions towards involvement in bedside ToA. Methods: In 2010-2011, nurse-to-nurse intershift bedside ToA was implemented at St. Michael’s Hospital (SMH) as the Registered Nursing Association of Ontario best practice guidelines. In 2012, the Nursing Advisory Council positioned the standardization of ToA processes as a corporate focus. To date, the standard approach has been implemented in all medical and surgical inpatient units at SMH. In 2012, a qualitative study was undertaken to explore patients’ perspectives of bedside nursing ToA on several units at SMH. Results: Since 2013, monthly audits show that compliance rates are above corporate target of 75% for nurses: 1) performing bedside ToA; 2) engaging patient and family; 3) using standardized checklist, and performing bedside safety checks. The qualitative research identified three emergent themes where patients perceived that ToA: 1) create a space for personal connection; 2) bump them up to speed, and 3) provide them preferences on their level of engagement. Video interviews showed that patients perceived ToA provide them an opportunity to be engaged in their care.

Conclusions: Qualitative findings highlight the need to engage patients to determine their desired level of involvement in ToA. Video testimonials captured patients’ and families’ report that involvement in ToA made them feel valued, safe and engaged. Despite these benefits, health care leaders and nurses need to take into account that there are varying preferences on the level of engagement and what information patients want to be disclosed or discussed during bedside nursing ToA.

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PRESENTATION 4 ID. 49 The Impact of a Community Re engagement Cue to Action Trigger Tool on the Transition Back to Valued Activities Post Stroke Donna Cheung, Jocelyne McKellar Toronto Stroke Networks Background: Persons with stroke are reluctant to or do not know what questions to ask their healthcare team during transitions to facilitate recovery and re-engagement back into the community.

Literature suggests that patients who ask questions improve their knowledge, confidence and control over their care.

Objective: This randomized control study evaluated an intervention using a patient-mediated question prompt list, Community Re-engagement Cue to Action Trigger Tool (CRCATT), on self-reported reengagement in valued activities post stroke.

Methods: The study employed a convergent parallel mixed methodology to provide perspectives on the persons with stroke’s experience through transitions towards community re-engagement (CR). Three to four months after enrollment, participants completed the Reintegration to Normal Living Index to measure satisfaction with CR. Responses were analyzed in SPSS. A sub-set participated in qualitative interviews to learn about the CRCATT intervention’s influence on CR. Qualitative responses were analyzed using an inductive approach with thematic analytic procedures.

Results: Seventy-seven participants were recruited from three stroke rehabilitation hospitals in Toronto. After statistically controlling for the effects of gender, level of education, age, language, and treatment group, no between group differences were observed due to small sample size. Correlational analysis suggest those with higher education are more likely to participate in valued activities.

Interview analysis revealed that participants’ ability to transition and re-engage are influenced by an interplay of the CRCATT with internal and external factors. These factors include social support, interactions with healthcare providers, personal attributes and one’s view of recovery.

Conclusions: The intervention was useful in assisting persons with stroke take a more self-directed role in their care by asking questions relevant to them and anticipating their needs. The tool complemented the external and internal factors that persons with stroke draw on to support transitions, recovery and CR. Next steps include educating healthcare providers on strategies to empower their patients to better self-manage their care using learnings from the CRCATT intervention.

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Oral Presentation Abstracts Concurrent Session 4 Patients with Complex Care and Social Needs PRESENTATION 1 ID. 75 Coordinated Access to Care for Homeless People - Lessons Learned from 5 Years of CATCH Homeless, a Critical Time Intervention Informed Model of Care Michaela Beder, Vicky Stergiopoulos St Michael's Hospital Background: CATCH-Homeless is a Critical Time Intervention informed program started in 2010 to ensure smooth transitions between inpatient/emergency department care and the community for people experiencing homelessness. CATCH is a partnership of three major hospitals, a homeless shelter, a mental health agency, and a physician practice plan. Case managers see clients in the community, providing intensive support for rehousing, crisis intervention, and connecting clients to services. The program also has a family doctor and two psychiatrists who provide short-term healthcare access. CATCH provides services to clients who are marginalized in multiple ways, including through poverty, homelessnes, and mental illness.

Objective: To evaluate the CATCH-Homeless program.

Methods: The CATCH-Homeless program was evaluated using a mixed methods case study design to evaluate the program at 6 months post program start, assessing health status as well as qualitative continuity of care experience.

Results: CATCH-Homeless program is an innovative model that provides intensive services to a population that is often severely marginalized, and not able to access mainstream medical or psychiatric services.

Conclusions: Preliminary results indicate that clients experienced significant improvements in mental health, and a statistically significant decrease in admissions at 3 months. The rates of ED use and homelessness did not decrease.

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PRESENTATION 2 ID. 102 Safe, Smooth Transitions for High Risk Seniors - Improving Care through Collaboration Taryn MacKenzie, AnnMarie Dimillo, Melissa Waggott The Ottawa Hospital Background: The Regional Geriatric Program of Eastern Ontario (RGPEO), a coordinated network of Specialized Geriatric Services (SGS) within the Champlain LHIN, has the goal of optimizing health and independence of seniors from hospital to home and in the community. Many seniors transition between the SGS programs of Geriatric Emergency Management (GEM), Geriatric Assessment and Outreach Team (GAOT), and Geriatric Medicine Ambulatory Services and Day Hospital (GMAS-DH) at The Ottawa Hospital (TOH). GEM assesses seniors being discharged from the emergency department (ED) to identify those at risk, who would benefit from further specialized geriatric assessment and intervention Objective: To provide safe, effective and timely transitions of seniors between the GEM program at TOH, GAOT and GMAS-DH through innovative collaboration.

Method: Review of current process for all programs focused on effective transitions. The main issues identified were: long waitlist for GAOT services with inefficient triage process; long waitlist for urgent GMAS-DH appointments; inconsistent process within GEM to identify urgent referrals for GAOT and GMAS-DH; and inefficient client information sharing between programs. Stakeholder consultation occurred and solutions were developed including: updated referral process by GEM and GAOT to include urgency category; designation of a GAOT team leader who triaged and scheduled client referrals; creation of an urgency-based scheduling protocol within GMAS-DH; electronic documentation by all programs on a shared browser; ongoing education and frequent updates between programs.

Results: We observed timely transitions between our three programs with the waitlist for GAOT and GMAS-DH referrals decreasing by 50%. This may mean improved care for seniors being discharged from the ED to our community as a result of rapid access to SGS and efficient sharing of vital patient information.

Conclusions: This cost neutral innovation provides high risk seniors within the Champlain LHIN with smooth, safe transitions between the hospital and community using a collaborative approach to improve their care.

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PRESENTATION 3 ID. 141 A Primary Care Practice-Based Intervention to Reduce ED Visits and Hospitalization for Complex Patients Laura Pus, Tara O'Brien, Onil Bhattacharyya, Noah Ivers, Ian Stanaitis, Steven Friedman, Pauline Pariser, Geetha Mukerji, Howard Abrams, Gillian Hawker Women's College Hospital, University Health Network, University of Toronto Background: Poor access to timely consultative services, uncoordinated care and difficulty in navigation of the healthcare system may be contributing to avoidable ED visit and hospital admissions for complex patients. Seamless Care Optimizing the Patient Experience (SCOPE) was a collaboration between acute and community providers (University Health Network, Women’s College Hospital, Toronto Central CCAC, and solo community primary care physicians (PCPs)) aimed at improving care delivery for complex patients.

Objective: The initiative aims to strengthen the relationship between hospitals, primary and community care to improve care for complex patients who are high users of emergency departments (EDs). SCOPE offered PCPs a single access point to interdisciplinary supports, providing timely access to healthcare resources. SCOPE enhanced PCPs ability to communicate with hospitalists while their patients were admitted and upon discharge.

Methods: The final outcome measure was the rate of ED visits for patients in participating practices.

The final outcome analysis was performed as a time series analysis with propensity-matched cohort. A qualitative analysis using semi structured one-on-one interviews was also undertaken.

Results: The SCOPE intervention, which was implemented for an 18 month period, demonstrated no difference in the per practice rate of ED visits when comparing pre and post rates for the SCOPE PCPs and controls. While the SCOPE intervention did not significantly reduce the rate of ED visits, qualitative analysis demonstrated that the intervention had positive impacts on improving PCP practice management and quality of care provided to patients. Feedback from the qualitative interviews demonstrated: 1) PCPs are more knowledgeable about the services available and therefore can offer an increased number of resources to their patients; 2) PCPs are more likely to find appropriate resources, and 3) PCPs have increased ability to practice shared care for their complex patients within an interdisciplinary environment.

Conclusions: The SCOPE intervention has been valuable in learning about the challenges solo PCPs face in caring for their complex patients. PCPs have different practice styles and preferred methods of communication, interventions need to be customized, practical and adaptive.

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PRESENTATION 4 ID. 142 Familiar Faces in Mental Health and Addictions in the ER: Transitioning Individuals from Acute Care Emergency Room to Community Services - Successes and Challenges from the Ottawa Experience Colleen MacPhee, Donna Pettey The Ottawa Hospital, Canadian Mental Health Association - Ottawa Branch Background: On a daily basis, 25 individuals present with mental health or addictions as primary reason for coming to the TOH Emergency Rooms. This represents 6% of all the ER visits. Of these presentations, 17- 22% have been seen within the past 30 days; this is above provincial targets. We collaborated with a community partner to engage individuals meeting specific criteria to community services to provide short term case management and system navigation within Ottawa addictions and mental health community services for individuals between 16-65.

Objective: We worked with community partners in addictions and mental health, TOH Emergency, and TOH Mental Health Programs to determine how to integrate and sustain a newly funded program of community mental health and addictions system navigators.

Method: We reviewed the process of identifying target group for service, and established an e-trigger identification and referral process. This facilitated the development of demographic profiles of individuals served and provided a place for comments on the service from the client’s perspective and identification of successes and challenges.

Results: Real time data provided demographic profiles of familiar faces in ER and reflected daily utilization of individuals presenting with mental health and addiction issues in ER. The data show a different demographic profile from more long term caseloads of Canadian Mental Health Agency; they are younger, educated, with addictions not the primary issue, and seeking interventions years before traditional referral processes for community mental health. These data reflect inadequate or difficult community access for our community that need to be addressed.

Conclusions: Sustaining these types of initiatives involves constant involvement from partner agencies.

If we are to find proactive solutions to decrease repeat ER visits for individuals who do not need the ER resources we need to collaborate outside walls of organizations and provide structure to safely transition individuals to other models of care.

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Oral Presentation Abstracts Concurrent Session 5 New and Emerging Models of Collaborative Care Focusing on all Transition Points PRESENTATION 1 ID. 48 Implementation of an Innovative Transition Navigator Role to Support Adolescents and Young Adults with Hemoglobinopathies Brooke Allemang, Suzan Williams, Geraldine Cullen-Dean, Melina Cheong, Colleen Johnson, Richard Ward - Hospital for Sick Children, Toronto General Hospital Background: In an effort to provide continuous care and reduce morbidity and mortality for patients with hemoglobinopathies transitioning from SickKids to Toronto General Hospital (TGH), an innovative transition navigator (TN) role was implemented. This position is the first of its kind to be established at either institution, with cross appointment at the adult and pediatric sites. The TN works with adolescents and young adults (AYA) from the age of 12-25 years with a focus on education and support, liaises between the pediatric and adult teams, develops resources, coordinates monthly transfer clinics and provides continuity of care by following AYA post-transfer.

Objective: To assess the impact of the transition program in its entirety, including the TN role.

Method: Readiness surveys have been completed by 243 patients between 12-18 years to assess knowledge of condition and self-management skills. Monthly transfer clinics have been attended by a total of 50 patients who completed post-clinic surveys about their experience. In the first year, 54 patients successfully transitioned to TGH. Results: Results from the readiness survey indicated that AYA with hemoglobinopathies have knowledge gaps in the following areas: time alone with care providers, contraception, sexual health/ puberty, diagnosis, and substance use. Interim analysis demonstrated that 98% of patients rated the transfer clinic as good/excellent and 98% felt better prepared for adult care. 95% of patients have attended their first appointment since the inception of the TN. The overall transition experience was rated as excellent by 70% of patients post-transfer.

Conclusions: The first year of the comprehensive transition program, including the innovative TN role, has yielded promising results. Patients and families are satisfied with the transition process and report feeling better prepared for adult care. Attendance at TGH appointments has improved. Next steps include a comparison of appointment attendance and medication adherence pre- and posttransition program to determine its impact.

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PRESENTATION 2 ID. 103 Collaborative Care Transitions in Adult Concussion: A New Model of Care Cindy Hunt, Alicja Michalak, Jennifer Vachhrajani, Chrisanthi Lefkimmiatis, Alun Ackery, Dan Abourbih, Pam Lovell, Andrew Baker, Donna Ouchterlony St. Michael’s Hospital Background: Concussion is a large public health issue with an incidence of 600/100,000 across Ontario. One-fifth of adults with concussion experience persisting symptoms for months to years including post traumatic headache, sleep disturbance, disorders of balance, cognitive impairments, fatigue dizziness and mood disorders. Symptoms often are unrecognized by the patient/family until they become debilitating. Achieving timely access to appropriate care after the initial emergency department (ED) visit is challenging. Wait time for specialty clinics are 9-12 months. While waiting, patients make an average of 36 provider visits, resulting in an average direct cost of $3,000 per person.

These delays further contribute to decreased quality of life, time lost from work, school, community and family activities.

Objective: To improve patient outcomes from concussion while also reducing repeat ED visits and decreasing the strain on the healthcare system (often from excessive visits to many other providers).

Method: This is collaborative initiative between the St. Michael’s Hospital Head Injury Clinic (HIC) and ED. It involves the Rapid Assessment Zone coordinators, patient education packages, a provider decision tool (PAT-10) and a new virtual concussion care clinic. The PAT-10 is implemented via telephone by a nurse within 10 days post discharge from ED. The nurse supports care transitions from ED to one of the following: HIC, concussion care clinic, family practice, a second phone call from the nurse or self- monitoring at home.

Results: To date, the nurse has contacted 350 ED concussion patients over the past 18 months. 10% met the criteria and were served in the HIC in a timely manner. Data shows 24% had repeat ED visits, while provider anecdotal evidence supports a higher rate of repeat ED visits prior to the innovation.

Conclusions: This model has optimized HIC patient flow, helped to reduce lengthy and costly wait times from excessive care. A prospective study to evaluate the effectiveness of the new transitions model will be undertaken.

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PRESENTATION 3 ID. 112 An Interprofessional Approach to Post Discharge/ER Visit Follow-up: Minding the Gap between Acute and Primary Care Vicki Bassett, Doreen O’Sullivan, Cynthia Way, Elizabeth Contestabile, Gemma Basilio The Ottawa Hospital, Academic Family Health Team Background: Care transitions from acute care to primary care have been identified as a time of vulnerability and risk for patients and families. Harm can arise from medication errors, lack of follow-up of pending inpatient test results, and inadequate communication between inpatient and primary care providers. Recently care transitions have become an important patient quality and safety focus for both acute care and primary care organizations.

Objective: To collaborate as a team, and to provide timely telephone follow-up for patients of our primary care Family Health Team, who have recently visited the ER, or have been discharged home from hospital.

Method: Process maps were developed by the team to standardize the approach to telephone follow-up. Roles of team members were defined and a documentation template for our Electronic Medical Record was implemented which incorporated evaluation data. Staff education was completed and the project was implemented in March 2015.

Results: The time frame for evaluation was March 1, 2015 to August 31, 2015. The total number of calls was 521. 67% of calls were post-ER visit and 33% were post-discharge. 88% of the post-discharge calls were made within the 3-7 day target time frame and 87% of the post-ER visit calls were made within the 14 day target time frame. Actions resulting from the calls were categorized. The most common actions were: appointment booked (28%) and patient education (26%). All patients were assessed for pain which is often an issue post-discharge. 99% of patients found the call helpful and in several cases serious harm may have been prevented by the call. Team feedback included an interesting observation that calls provided an opportunity to reinforce the urgent care service offered by the Family Health Team, so that perhaps a return visit to the ER could be avoided in certain situations. Although there were some challenges with call volumes in the summer months, team satisfaction with the new process is high.

Conclusions: Telephone follow-up by primary care teams post-discharge and post-ER visit is helpful to patients and families and is a promising intervention in closing the gap in acute and primary care transitions.

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Oral Presentation Abstracts Concurrent Session 6 Experiences and Perceptions of Patients, Families and Providers Toward Care Transitions PRESENTATION 1 ID 52 Engaging Patients and Families in Experience-based Co-design of the Admission Process Doreen Watts, Agnes Tong- Bridgepoint Hospital, Sinai Health System Background: Bridgepoint Hospital - Sinai Health System is a 404 bed rehab/Complex Comprehensive Care (CCC) hospital designed to enable patients to be active in their care. With government funding and clinical best practice requirements to shorten the length of stays, the first 48 hours from admission is a critical time for patients/families and the team. Patients arrive from acute care feeling overwhelmed with information, the new environment and the short length of stay. The interprofessional team has to quickly establish the patients goals, plans of care/treatment and set the discharge date.

Objective: This project aims to achieve exceptional patient experience with the admission process by capturing and understanding their experience, partnering with them to co-design the first 48 hours of hospital stay. This project received a grant from the Canadian Foundation for Healthcare Improvement.

Methods: Using Experience by Co-design methodology, we captured the patient and staff experience with the current admission process on the orthopedic unit. Based on outcomes, patients together with staff co-designed priority ares in the first 48 hours of care. Patients and staff identified and implemented change ideas using quality improvement principles, tested and evaluated change. Process outcomes and balancing measures were put into place to determine whether the changes resulted in improvement.

Results: Patients informed us to shift the burden from the admitted to discharged patients, so new patients in pain are not waiting for a bed on admission. Together we revised a disharge slip providing patients with the date of disharge. We co-designed a discharge checklist “Ready to go.” Patients are given this tool 5 days before their disharge date to help them get ready to go home. We shifted the hospital discharge time of 10am to 09am to create bed capacity for new admissions. Since May 2015 patient satisfaction is very high 95-100%, more admissions have been arriving before 10am [43% (May-Sept 2015) vs. 35% in FY 14/15] our patients have been leaving earlier with 67% leaving before the discharge time of 10am compared to 49% in FY14/15. Only 1 patient has waited for a bed.

Conclusions: Engaging patients and capturing their experience and partnering with them to codesign processes benefits patients and staff to provide better, more efficient care.

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PRESENTATION 2 ID 111 Exploring the Self-management Needs of Transitioning Young Adults with Osteogenesis Imperfecta into Adult Primary Care Services: Preliminary Findings Alisha Michalovic, Charlotte E. Anderson, Argerie Tsimicalis, Kelly Thorstad, Sharon Brissette, Lucyna Lach, Frank Rauch McGill University, Shriners Hospitals for Children-Canada, CIUSSS du Centre-Ouest-de-l’île de Montréal Background: Youth with chronic conditions are at a heightened risk for various adverse health outcomes once transitioned from the pediatric to the adult healthcare system. The Shriners Hospitals for Children- Canada (SHC) is seeking to improve the transition services provided to the osteogenesis imperfecta (OI) population by (a) creating partnerships with the adult primary care settings, (b) providing OI training to the adult nurse practitioners, and (c) improving the self-management skills of our transitioning OI population.

Objective: To explore the future and current self-management needs of transitioning young adults with OI as they transition from pediatric to adult primary care.

Methods: A longitudinal qualitative descriptive study is currently in progress at SHC and CSSS de la Montagne (an adult primary care setting) with a convenient sample of up to 20 participants who agree to be seen by an adult nurse practitioner. Eligible participants consist of young adults with OI who were former SHC patients. Two semi-structured interviews are conducted with the participants, which focus on their self-management needs before and after they transition into an adult primary care setting. Genograms and eco-maps are also created with the participants to provide a graphical representation of their family structure, resources and support networks. Data are descriptively analyzed.

Results: To date, 4 participants have participated in 6 interviews (4 before and 2 after transition).

Participants include those diagnosed with OI type III (n = 2) and OI type IV (n=2), and range in age from 23 to 34 years. Emerging themes suggest a desire for a home and work environment that promotes independence, knowledge and resources to help navigate the adult healthcare system, access to a primary healthcare provider knowledgeable about OI, a need for social support from the adult OI community, and a desire to maintain their longstanding relationship with SHC. Conclusions: Findings generated from this study may inform our goals to provide a seamless transition into the adult system, ensure our patient population has the knowledge and skills to successfully navigate the system, and our adult practitioners have the knowledge to care for this rare genetic condition.

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PRESENTATION 3 ID 125 A Major Healthcare Transition Milestone: Experiences and Needs of Parents of Preterm Infants Transitioning from Neonatal to Developmental/ Rehabilitation Services Marilyn Ballanytne, Taryn Orava, Stephanie Bernardo, Amy McPherson, Paige Church, Darcy Fehlings Holland Bloorview Kids Rehabilitation Hospital, Sunnybrook Health Sciences Centre Background: Children with cerebral palsy (CP), who were born preterm (<37 weeks), have complex medical needs requiring transition to and from many healthcare institutions over their lifespan.

While an abundance of research outlines the experiences and needs of patients and families during the transition to home, school, adult care, long-term care, and palliative care; very little is known about the transition from neonatal services to developmental/ rehabilitation services. Researchers and practitioners have little knowledge of stressors encountered, and types of supports required to help patients and their families successfully cope with this healthcare milestone.

Objective: To identify and describe the experiences and needs of parents of children with CP, who were born preterm, as they transition from neonatal services to developmental/rehabilitation services.

Methods: Phase 1: Scoping review identifying experiences and needs of parents of infants/children (<13 years) as they transitioned within or between healthcare settings. Eight databases were reviewed by three researchers, eligible articles selected, and data were extracted for experiences and needs. Phase 2: Interviews with Holland Bloorview Kids Rehabilitation Hospital (HB) parents of children with CP, who were born preterm, Interviews were audio-recorded, transcribed verbatim, and underwent a thematic analysis.

Results: From 7,890 retrieved titles, 12 articles met eligibility criteria. No study focused on transition to developmental/rehabilitation services. Positive experiences were defined by: provision of information, feeling involved in care, and improved child health outcomes post-transition. Negative experiences were defined by: inadequate information or communication, fearing the unknown, feeling separated from their child, and unexpected differences within the new healthcare setting. Parent needs included: more information, emotional support, being part of the healthcare team, and instrumental assistance by families/friends. Themes were reiterated in HB parents’ interviews: feeling uncertain, receiving little information, and limited support to cope with changes.

Conclusions: Themes emerging from this research are not uncommon to the many types of healthcare transition experienced across the lifespan. There is an opportunity to support families’ resiliency and preparedness earlier in their journey of healthcare transitions, which will ultimately lower stress, embody family-centered care, and improve child health.

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Poster Presentations Patients with Complex Care and Social Needs Poster ID: 27 - Quality Improvement Evaluation of a Medication Education Program for Transplant Recipients Lucy Chen, St. Michael's Hospital Poster ID: 88 - Research Identifying Effective Nurse-Led Care Transition Interventions for Complex Older Adults Using a Structured Expert Panel Lianne Jeffs, Sharon Straus, Monika Kastner, St. Michael’s Hospital/Li Ka Shing Knowledge Institute, Vera Nincic, Maria Maione, Marianne Saragosa, Ella Ferris, St. Michael’s Hospital Madelyn Law, Brock University; Kerry Kuluski, Lunenfeld-Tanenbaum Research Institute Sherry Espin, Ryerson University; Chaim Bell, Jane Merkley, Sinai Health System Brenda Dusek, formerly with the Registered Nurses Association of Ontario Poster ID: 92 - Quality Improvement The Transitional Care Specialist: Supporting Complex Hospitalized Patients in Their Return Home Agnes Kulinek, Toronto Western Hospital Poster ID: 102 - Quality Improvement Safe, Smooth Transitions for High Risk Seniors – Improving Care through Collaboration Taryn MacKenzie, AnnMarie Dimillo, Melissa Waggott, The Ottawa Hospital Poster ID: 117 - Quality Improvement Timing is Everything: Leading Our Teams to Implement Early Social Work Referral as a Best Practice Impacting Readmissions Heather McKenna, Karen Nelson, Tamzin Cathers, The Ottawa Hospital, Stanford Health Care Poster ID: 130 - Quality Improvement Smooth Transitions: Importance of Self-management for Cystic Fibrosis Patients Moving from Paediatric to Adult care Susan Carpenter, Kate Gent, Hospital for Sick Children, St. Michael's Hospital Poster ID: 141 - Quality Improvement A Primary Care Practice-Based Intervention to Reduce ED Visits and Hospitalization for Complex Patients Laura Pus, Tara O'Brien, Onil Bhattacharyya, Noah Ivers, Ian Stanaitis, Steven Friedman, Pauline Pariser, Geetha Mukerji, Howard Abrams, Gillian Hawker Women's College Hospital, University Health Network, University of Toronto Poster ID: 142 - Quality Improvement Familiar Faces in Mental Health and Addictions in the ER: Transitioning Individuals from Acute Care Emergency Room to Community Services - Successes and Challenges from the Ottawa Experience Colleen MacPhee, Donna Pettey The Ottawa Hospital, Canadian Mental Health Association - Ottawa Branch 32

St. Michael’s Hospital

Poster Presentations New and Emerging Models of Collaborative Care Focusing on all Transition Points Poster ID: 38 - Quality Improvement Toronto East General Hospital and Toronto Central CCAC: Partners in Alternative Level of Care Transitions Lindsay Martinek, Debbie Guyader - Toronto East General Hospital, Toronto Central CCAC Poster ID: 46 - Quality Improvement Improving Patient-Family Discharge Experiences through Follow-up Phone Calls Francesca Damian, Lauren Scavuzzo-The Hospital for Sick Children Poster ID: 48 - Quality Improvement Implementation of an Innovative Transition Navigator Role to Support Adolescents and Young Adults with Hemoglobinopathies Brooke Allemang, Suzan Williams, Geraldine Cullen-Dean, Melina Cheong, Colleen Johnson, Richard Ward Hospital for Sick Children, Toronto General Hospital Poster ID: 74 - Research Patients First: Improving Communication of Current Medication Use During Transitions Lynn Sharon Wilson, Delayna Podgers , Anne Campbell , Kris Walker Rural Kingston Family Health Organization/ Verona Medical Clinic, Kingston General Hospital, SELHIN Community Access Centre Poster ID: 76 - Quality Improvement “There are Many Avenues to Rehab”: Standardizing Communication About Discharge Planning in Acute Stroke Care Moira Teed, Isabelle Martineau, Beth Nugent, Jim Lumsde-Champlain Regional Stroke Network Poster ID: 85 - Quality Improvement Co-Creating a New Foundation for Community Stroke Care Donna Cheung, Nicola Tahair, Sylvia Quant, Jacqueline Willems, Shelley Sharp, Elizabeth Linkewich, Cary Fan, Donna Renzetti, Jocelyne McKellar- Toronto Stroke Network, Toronto Rehab, West Park Healthcare Centre Poster ID: 87 - Research Knowing Each Other’s Work: Evaluating the Impact of Essential Professional Conversations on Care Collaboration at Times of Transition and Gaining Insights for Sustainability Sherry Darling, Sylvia Quant, Gail Avinoam, Shelley Sharp, Beth Linkewich, Jacqueline Willems, Cate Creede Toronto West Stroke Network, North & East GTA Stroke Network, South East GTA Stroke Network, The Potential Group Poster ID: 89 - Quality Improvement Impacting Stroke Patient’s Length of Stay with Earlier Rehabilitation Referrals Sandy Gill, Melissa Alves, Mary Van Impe, Jacqueline Willems - St. Michael’s Hospital Collaborative Care Transitions Symposium

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Poster ID: 94 - Research An Innovative Model Of Care and Electronic Solution to Engage Clinicians In Facilitating Testicular and Endometrial Cancer Patients Transition to Post-Treatment Survivorship Doris Howell, Sarah Ferguson, Padraig Warde, Menaka Pulandiran, Beth Edwards, Jennifer M Jones University of Health Network, Princess Margaret Cancer Centre Poster ID: 101 - Quality Improvement Medication Reconciliation: Creating a Custom Form Kyle Lee, Monique Moller, Brenda Chang, Tara Kiran, Noor Ramji, Lisa Miller, St. Michael's Hospital Poster ID: 103 - Quality Improvement Collaborative Care Transitions in Adult Concussion: a New Model of Care Cindy Hunt, Alicja Michalak, Chrisanthi Lefkimmiatis, Jennifer Vachhrajani, Alun Ackery, Dan Abourbih, Pam Lovell, Andrew Baker, Donna Ouchterlony, St. Michael's Hospital Poster ID: 104 - Quality Improvement Telemedicine Interprofessional Model of Practice for Aging and Complex Treatments (IMPACT) Plus Program (TIP) - A ”Virtual” Interprofessional Complex Care Clinic at the St. Michael’s Hospital Di Wang, Carol Flewelling, Priscilla Tang, Karen Weyman St. Michael's Hospital Academic Family Health Team, St. Michael's Hospital Telemedicine Program University Health Network Telemedicine IMPACT Plus (TIP) Poster ID: 105 - Quality Improvement Collaborative Partnerships for Complex Transitions – Creating a Complex Care Task Force to Identify and Help Youth with Complex Care Needs Transition to Adult Services Khush Amaria, Megan Henze, Geraldine Cullen-Dean, Miriam Kaufman, Melanie Randall Hospital for Sick Children, Surrey Place Poster ID: 106 - Quality Improvement Complex Youth with Complex Transitions: Developing Service Navigation Pathways Khush Amaria, Megan Henze, Geraldine Cullen-Dean, Miriam Kaufman, Hospital for Sick Children Poster ID: 107 - Quality Improvement Interprofessional Collaborative Pre-Admission Interview Model with Clinical Focus on Nunavut Clients Emily Deacon, Mathieu Dufour, Stephanie Brooks, Susan Farrell, Royal Ottawa Health Care Group Poster ID: 110 - Quality Improvement Responsive Behaviours in Hospital: Challenges to Long-Term Care Transitions Andrea Perry, Heather Cholack-University Health Network Poster ID: 112 - Quality Improvement An Interprofessional Approach to Post-Discharge/ER Visit Follow-up: Minding the Gap between Acute and Primary Care Vicki Bassett, Doreen O’Sullivan, Cynthia Way, Elizabeth Contestabile, Gemma Basilio The Ottawa Hospital, Academic Family Health Team 34

St. Michael’s Hospital

Poster ID: 116 - Quality Improvement Hospital to Home - Facilitating Medication Safety at Transitions: A Toolkit and Checklist for Healthcare Providers Lisa Sever, Alice Watt, Dorothy Tscheng - Institute for Safe Medication Practices Canada Poster ID: 122 - Quality Improvement Two Teams Become One: Enhancing Transitions Along the Continuum of Care in Amputee Rehabilitation Amanda Mayo, Siobhan Donaghy, Cathy Pupo, Diana Goliss, Marie Disotto-Monastero, Jennifer Shaffer, Sunnybrook Health Sciences Centre, St. John's Rehab Poster ID: 123 - Quality Improvement Supporting Frail Seniors in Regaining Independence: The Central LHIN Assess and Restore Pilot Program Alysia R Catalano, Susan Woollard, Jennifer E Scott-North York General Hospital, Central Community Care Access Centre Poster ID: 127 - Quality Improvement Transition Planning Process Improvement in Psychiatric Inpatient - A LEAN Green Belt Project Rita Desai, Jyll Simmon-Center for Addiction and Mental Health Poster ID: 133 - Quality Improvement Smooth Transitions in Care for Hospitalized Seniors Nancy Corcoran, Dana Naylor, Jonathan H Wiersma-Royal Victoria Regional Health Centre Poster ID: 153 - Quality Improvement Building Case Management Today for Tomorrow Joan Park-St. Michael's Hospital Poster ID: 158 - Quality Improvement Improving High User Outcomes Through Technology, Innovation and Partnership - A Case Study of the Chatham-Kent Health Links Initiative Nancy Snobelen-Chatham-Kent Health Alliance Poster ID: 166 - Quality Improvement Transfer of Accountability among the Operating Room (OR), Post Anesthesia Care Unit (PACU), and Intensive Care Units (ICUs) Melissa Guiyab, Nancy Rudyk, Pamela Mclachlan, Debbie Snatenchuk, Joyce Grandy, Carolina GomezBuiles, Lisa Horton, Mary Mustard, Marcia Sartorio, Kataneh Dadashi-St. Michael's Hospital Collaborative Care Transitions Symposium

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Poster Presentations Experiences and Perceptions of Patients, Families and Providers Toward Care Transitions Poster ID: 49 - Research The Impact of a Community Re-engagement Cue to Action Trigger Tool on the Transition Back to Valued Activities Post Stroke Donna Cheung, Jocelyne McKellar-Toronto Stroke Networks Poster ID: 50 - Quality Improvement Improving Transitions in a Post Acute/Sub Acute Healthcare Environment through Engagement, Partnership and Co-design with Patients and Families Sandra Schmidt, Debbie Gravelle, Beverley Shea, John Robinson, Jacqueline Tetroe, Maria Judd Bruyere Continuing Care, Bruyere Research Institute, Canadian Foundation for Healthcare Improvement Poster ID: 58 - Quality Improvement Learning With and From One Another; Patients and Providers on the Same Improvement Path Valentina Constantinescu-St. Joseph's Healthcare Hamilton

Poster ID: 68 - Quality Improvement Improving Nurse to Nurse Transfer of Accountability in a Palliative Care Unit Victoria McLean, Slawomir Zulawnik-St. Michael's Hospital

Poster ID: 80 - Research Peers Fostering Hope: Peer Support as a Complement to Stroke Care in Acute and Rehabilitation Jocelyne McKellar, Donna Mackay-Toronto Stroke Networks, March of Dimes Canada

Poster ID: 83 - Research Transfer Clinics: Supporting Youth with Special Health Care Needs in the Move from Pediatric to Adult Health Care Khush Amaria, Geraldine Cullen-Dean, Megan Henze, Miriam Kaufman-Hospital for Sick Children

Poster ID: 100 - Quality Improvement Pathways Addressing Transitions in Healthcare (PATH): A New Approach to Clinical Nursing Education Anne Simmonds, Joanne Louis, Shirley Bell, Jordana Kashin, Zara Fischer-Harrison, Emily Arndt, Emma Makhakhe Lawrence S Bloomberg Faculty of Nursing, University of Toronto, St. Michael's Hospital 36

St. Michaelâ&#x20AC;&#x2122;s Hospital

Poster ID: 111 - Research Exploring the Self-Management Needs of Transitioning Young Adults with Osteogenesis Imperfecta into Adult Primary Care Services: Preliminary Findings Alisha Michalovic, Charlotte E. Anderson, Argerie Tsimicalis, Kelly Thorstad, Sharon Brissette, Lucyna Lach, Frank Rauch McGill University, Shriners Hospitals for Children-Canada, CIUSSS du Centre-Ouest-de-l’île de Montréal Poster ID: 115 - Research Are They Expecting Too Much? Unrealistic Expectations About Adult Healthcare in Teenaged Childhood Cancer Survivors Rebecca Wang, Iqra Syed, Ronald Barr, Norma M D’Agostino, Paul C Nathan, Anne F Klassen Queen's University, School of Medicine Faculty of Health Sciences, McMaster University Department of Pediatrics, McMaster University Department of Psychiatry, University of Toronto Department of Pediatrics, The Hospital for Sick Children and the University of Toronto Poster ID: 125 - Research A Major Healthcare Transition Milestone: Experiences and Needs of Parents of Preterm Infants Transitioning from Neonatal to Developmental/Rehabilitation Services Marilyn Ballanytne, Taryn Orava, Stephanie Bernardo, Amy McPherson, Paige Church, Darcy Fehlings Holland Bloorview Kids Rehabilitation Hospital, Sunnybrook Health Sciences Centre Poster ID: 138 - Quality Improvement Engaging Primary Care Providers in Care Coordination for Patients with Complex Medical Conditions Elizabeth Lockhart, Laura Pus, Gillian Hawker, Noah Ivers, Geetha Mukerji, Pauline Pariser, G. Ross Baker University of Toronto, Women's College Hospital, University Health Network Poster ID : 146 - Quality Improvement Reflections of Clients and Healthcare Team embers about the LIFEspan cross-organizational transitions service Dolly Menna-Dack, Allison Freeman Holland Bloorview Kids Rehabilitation Hospital & University Health Network

Poster ID: 165 - Research Enhancing the Patient Experience through Standardized Nurse-to-nurse Intershift Bedside Transfer of Accountability Cecilia Santiago, Murray Krock, Lianne Jeffs, Ella Ferris- St. Michael's Hospital

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Registration Desk

Registration Desk

Poster Presentations Map

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St. Michaelâ&#x20AC;&#x2122;s Hospital

Location These directions will bring you to St. Michael’s Hospital Li Ka Shing Knowledge Institute, 209 Victoria Street, Northeast corner of Shuter and Victoria Street.

TTC DIRECTIONS 1. Exit the subway at the Queen Subway station.

2. The Queen Subway station is on the Yonge-University-Spadina subway line.

3. Walk one block north on Queen Street to Shuter Street.

4. Turn right onto Shuter Street and walk east one block to Victoria Street. The Li Ka Shing Knowledge Institute is on the northeast corner of Shuter and Victoria Street.

DRIVING DIRECTIONS FROM THE DON VALLEY PARKWAY 1. Exit at Richmond Street 2. Go west to Victoria Street 3. Go north to Shuter Street

FROM THE GARDINER EXPRESSWAY 1. Exit at Jarvis Street 2. Go north to Shuter Street 3. Go west to Victoria Street

PARKING St. Michael’s Hospital offers public parking in a convenient location across from the hospital. The lot is open 24 hours, seven days a week, The entrance is located on Victoria Street just north of Shuter Street on the west side of the Li Ka Shing Knowledge Institute.

Parking inquiries should go to the lot manager James Parr at 416-369-1801 ext. 263.

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ACKNOWLEDGEMENTS Poster Adjudicators Elizabeth Butorac, Clinical Leader Manager, Trauma Neurosurgery Intensive Care Unit Sonya Canzian, Program Director, Trauma Neurosurgery & Mobility Wai-Hin Chan, Research Program Manager, Knowledge Translation Chris Hayes, Medical Director, Quality Improvement Cathy O'Neill, Director, Quality & Performance Nancy Rudyk, Clinical Leader Manager, Perioperative Services Judy Shearer, Program Director, Inner City Health Orla Smith, Director, Nursing/ Clinical Research Gail Wilson, Director, Clinical Systems Adoptions Marnee Wilson, Professional Practice Leader, Nurse Practitioners

IT/AV David Bennett, Audio Visual Technician Robert Danielsen, Audio Visual Technician

Medical Media Marcelo Silles, Graphic Artist Katherine Cooper, Video Photographer

Communications Melissa Di Costanzo, Senior Communications Advisor James Wysotski, Digital Communications Advisor

The Catering Department SMH Foundation The Print Shop

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St. Michaelâ&#x20AC;&#x2122;s Hospital

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