Currently in Hamilton, there are marginalized clients in the hospital who are ready to be discharged but need more supports to be able to transition to the community. Over the last year, North Hamilton Community Health Centre has been addressing this Alternate Level of Care (ALC) issue by partnering with local hospitals to provide appropriate primary care access to vulnerable clients.
The ALC issue is a symptom of a system wide problem, where patients who no longer require acute care are unable to transition to a more appropriate setting due to capacity issues, complex health and social needs, and various other reasons.
Health Quality Ontario had a chance to catch up with Elizabeth Beader, Chief Executive Officer and Kathy Allan-Fleet, Chief Operating Officer at North Hamilton to learn more about their ALC approach.
How did partnerships first develop with your local hospital systems?
As a Community Health Centre (CHC), we’ve been working with clients with complex needs for many years including recently incarcerated individuals and clients with refugee status. These vulnerable patients often don’t have access to primary care in the community. We work with partner agencies to set up direct referrals for these clients so that they have the primary care supports they need in their community. Our hospital partners were interested to leverage our expertise and community connections.
In addition, our CHC sits on various regional tables with local hospitals and other primary care and community support agencies to work together on issues affecting our Hamilton community. Through this forum, St. Joseph’s Healthcare, among other hospitals, approached us to brainstorm ways we could work together to transition complex clients from their hospital to the right primary care services in the community.
Members of the North Hamilton CHC team from left to right: Kathy Allan-Fleet, Dr. Darshana Mehta, Angela Ramlall and Justine Cole
Can you give an example of how your partnership works?
In November 2017, the Hamilton Niagara Haldimand Brant LHIN funded the St. Joseph’s Healthcare Dual Diagnosis Housing Program, a 10-bed community housing program for individuals with both intellectual and developmental disability and mental health concerns.
One of the requirements for clients to be transferred to the housing program from St. Joseph’s hospital is access to a primary care provider.Many clients who are in-hospital for a long time do not have a primary care provider. So, we worked with the hospital to develop a CHC direct referral process, which includes flagging these high priority clients and accepting them as patients at our CHC before they move to the housing program.
We guarantee acceptance into our CHC, which is an important step in transitioning clients out of the hospital.
A warm transition process was developed between the hospital, the case worker from the housing program and the CHC.The first primary care visit in the CHC is also coordinated for the client so that their medical needs can be met.
We have a client, called MJ, who was referred to North Hamilton CHC after his arrival in the Dual Diagnosis Supportive Housing Program. He is a 55 year old male who had been living in the hospital for the last five years.He had been diagnosed with Schizophrenia, chronic pain, hypertension and a moderate intellectual disability. MJ’s new physician at the CHC provides primary care while the outpatient psychiatrist at the hospital continues to provide care and manage his psychiatric medications. MJ is now getting help with his vision and recent hearing loss because of our ability to refer to community specialists. Because of our partnership with the hospital, MJ is now able to live in the community.
Did you experience any challenges while developing your partnerships?
At the start of the partnership with St. Joseph’s, our CHC was only getting bits of information about patients upon discharge because we don’t have access to hospital EMRs or their pharmacy data.
Hospitals and CHCs work differently and we needed some time to learn about each other’s ways of operating to smooth out processes. We also met with hospital staff to identify key individuals who worked on patient flow to help with communication.
After a few months of working with the hospital, we are now getting discharge sheets, medication information and much more information about patients. We had to learn to work together as two different organizations. Thankfully our hospital partners were open to finding ways to accommodate the challenges we faced.
Having ongoing clinician-to-clinician communications about clients was also important so that both the hospital psychiatrists and CHC doctors and other interdisciplinary team members had clear expectations about how our partnership would work. A benefit of our partnership is that clients can transition from our CHC to the hospital when required without needing a new referral. This allows them to bypass the waitlist and ensures timely access to care.
Do you have advice for other primary care organizations who want to work in partnership with hospitals?
Identifying key people from each organization is extremely important. Much of the work has been around building relationships and ironing out differences in how hospitals and CHCs work and operate. We’ve been privileged to have very open and continuing communication with our partner hospitals who are willing to improve processes while we learn how best to work together.
You may also be interested in: Using a multipronged approach to improve ALC: Spotlight on North Lambton CHC
Do you work on the issue of ALC at your organization? Reach out to Kathy Allan-Fleeton Quorum or add your questions or comments below.