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Indicators & Change Ideas

Are you looking to improve the issues facing today’s health care system?

 

Explore the quality indicators being tracked by health care organizations in Ontario through Quality Improvement Plans (QIPs) and change ideas to help improve them. Connect with others to share your experiences and ideas of your own.

INDICATORS & CHANGE IDEAS

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Improve transitions and access to integrated team-based care, including home and community care

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Alternate level of care (ALC) refers to a patient who is occupying a bed in hospital and waiting to receive care elsewhere. A designation of ALC can have negative effects on both the patient (for example, through risk of hospital-acquired harms such as infections, delirium, and functional decline while in hospital) and the health care system (for example, through high costs and decreased access to acute services for patients who truly require them). In Ontario, greater than 80% of ALC designations in acute care are attributed to older adults 65 years of age and over, with the largest cohort, 64%, over the age of 75 (Ontario Health Access to Care). It is important to understand the population that is most at risk of becoming ALC and how they access care across the continuum within the local Ontario Health Team (OHT) context.

In 2023/24, hospitals across the province took an important next step toward identifying the root causes of delayed transitions in care through completion of the ALC Leading Practices Self-Assessment. Many OHTs and community health service providers have also engaged in similar processes to assess themselves against leading practices in community-based early identification, assessment, and transition. Collectively, this work helps to define the current state across the continuum and establishes a baseline for improvement from which OHTs can plan and integrate change initiatives that support overall access to care in the most appropriate setting.

Key Resources

Change Ideas

Conduct asset mapping to understand what services are available for the population and wait times

Include patients and care partners as part of the care team

  • Develop care plans and goals of care collaboratively with patients and care partners
  • Implement an approach to measuring patient and care partner experiences and outcomes

Optimize processes for early identification, assessment, and care plan development in the community and prior to ALC designation

  • Use a screening process or tool to identify patients at risk for loss of independence and in need of care
  • Identify and document patients’ baseline functional status
  • Complete comprehensive assessment that addresses physical, cognitive, functional, and psychosocial domains
  • Determine patients’ functional goals and restorative potential to inform the care plan
  • Develop care plans to address identified care needs with a focus on remaining in the community

Across sectors, support patients with behaviours and those at risk of deconditioning

Follow best-practice rehabilitation, community, and long-term care pathways

Transition patients requiring palliative support back to the community

  • Use evidence-based tools to identify individuals who would benefit from palliative care
    The Ontario Palliative Care Network’s Tools to Support Earlier Identification for Palliative Care outlines recommended tools that can be integrated into various settings of care
  • Implement an evidence-based model of care for providing palliative care in community settings
    The Ontario Palliative Care Network’s Palliative Care Health Services Delivery Framework outlines recommendations to guide organization and delivery of palliative care and includes a patient pathway (see page 16)
  • Foster collaboration and communication internally and across care settings to support discharge to home or to other dedicated end-of-life settings
    Explore virtual platforms for connecting with specialists or with patients, especially in remote areas (e.g., Ontario Telemedicine Network’s eConsult, eVisits, and Virtual Palliative Care programs)
    Reach out to ProvincialPalliativeCareProgram@OntarioHealth.ca for information on supports and partners in your local area
    Share resources (staff, technology, or training opportunities) among partners in your region (e.g., sharing and co-funding a nurse practitioner among partners within a region, holding regional educational events)

Transition patients requiring support to age in place back to the community

Improve transitions and access to integrated team-based care, including home and community care

0 Comments

Alternate level of care (ALC) refers to a patient who is occupying a bed in hospital and waiting to receive care elsewhere. A designation of ALC can have negative effects on both the patient (for example, through risk of hospital-acquired harms such as infections, delirium, and functional decline while in hospital) and the health care system (for example, through high costs and decreased access to acute services for patients who truly require them). In Ontario, greater than 80% of ALC designations in acute care are attributed to older adults 65 years of age and over, with the largest cohort, 64%, over the age of 75 (Ontario Health Access to Care). It is important to understand the population that is most at risk of becoming ALC and how they access care across the continuum within the local Ontario Health Team (OHT) context.

In 2023/24, hospitals across the province took an important next step toward identifying the root causes of delayed transitions in care through completion of the ALC Leading Practices Self-Assessment. Many OHTs and community health service providers have also engaged in similar processes to assess themselves against leading practices in community-based early identification, assessment, and transition. Collectively, this work helps to define the current state across the continuum and establishes a baseline for improvement from which OHTs can plan and integrate change initiatives that support overall access to care in the most appropriate setting.

Key Resources

Change Ideas

Conduct asset mapping to understand what services are available for the population and wait times

Include patients and care partners as part of the care team

  • Develop care plans and goals of care collaboratively with patients and care partners
  • Implement an approach to measuring patient and care partner experiences and outcomes

Optimize processes for early identification, assessment, and care plan development in the community and prior to ALC designation

  • Use a screening process or tool to identify patients at risk for loss of independence and in need of care
  • Identify and document patients’ baseline functional status
  • Complete comprehensive assessment that addresses physical, cognitive, functional, and psychosocial domains
  • Determine patients’ functional goals and restorative potential to inform the care plan
  • Develop care plans to address identified care needs with a focus on remaining in the community

Across sectors, support patients with behaviours and those at risk of deconditioning

Follow best-practice rehabilitation, community, and long-term care pathways

Transition patients requiring palliative support back to the community

  • Use evidence-based tools to identify individuals who would benefit from palliative care
    The Ontario Palliative Care Network’s Tools to Support Earlier Identification for Palliative Care outlines recommended tools that can be integrated into various settings of care
  • Implement an evidence-based model of care for providing palliative care in community settings
    The Ontario Palliative Care Network’s Palliative Care Health Services Delivery Framework outlines recommendations to guide organization and delivery of palliative care and includes a patient pathway (see page 16)
  • Foster collaboration and communication internally and across care settings to support discharge to home or to other dedicated end-of-life settings
    Explore virtual platforms for connecting with specialists or with patients, especially in remote areas (e.g., Ontario Telemedicine Network’s eConsult, eVisits, and Virtual Palliative Care programs)
    Reach out to ProvincialPalliativeCareProgram@OntarioHealth.ca for information on supports and partners in your local area
    Share resources (staff, technology, or training opportunities) among partners in your region (e.g., sharing and co-funding a nurse practitioner among partners within a region, holding regional educational events)

Transition patients requiring support to age in place back to the community

Aaron Miller True