William Osler Health System identified that patients with major depression were not always receiving timely access to mental health and addictions treatment following discharge from the Mood and Anxiety Adult Inpatient Unit at the Brampton Civic Hospital
Osler Health System.
Osler recognized that when patients who are still suffering from depression deteriorate due to lack of timely community support, they often have no alternative but to revisit the hospital services, often in crisis.
A team of passionate health care professionals at Osler participated in the IDEAS Program to find ways to ensure timelier follow-up care and improve transitions to home.
They used Health Quality Ontario’s Quality Standard for Major Depression as the basis for their quality improvement project and focused on Quality Statement 12: Transitions in Care:
“People with major depression who transition from one care provider to another have a documented care plan that is made available to them and their receiving provider within 7 days of the transition, with a specific timeline for follow-up. People with major depression who are discharged from acute care have a scheduled follow-up appointment with a health care provider within 7 days.”
As a result, 65% of patients now have a follow-up appointment with a health care provider (such as a psychiatrist, family physician, or community partner) scheduled within 7 days of discharge, and the average wait for a follow-up appointment has dropped from 17 days to 9 days.
Post-discharge is a vulnerable time for patients affected by major depression. They may be a serious safety risk to themselves because there is a higher likelihood of suicide during the two weeks following discharge from hospital psychiatric treatment programs.
When Osler looked at their internal data, they found that post-discharge appointments were not being consistently made for patients as part of the discharge planning process. When appointments were made prior to discharge, it was often late in the patient's hospitalization—this led to increased wait times for post-discharge follow-up, which in turn led to increased risks for the patient.
Osler also recognized that expecting patients to make their own follow-up appointments after discharge from hospital is not the best way to support follow-up care.
The Osler team including Tina Smith Krans, Mary Anne Oribhabor, Martine Lopez, Dr. Navin Kaicker, with the support of their manager Shailesh Nadkarni, met with front line staff and psychiatrists to build support for trying small changes in an incremental fashion. Using improvement science methodology, they took the time to understand the current state and discovered opportunities for improvement.
The Osler team set an aim that 75% of patients with major depression discharged from the inpatient unit would be offered a scheduled follow-up appointment with a health care provider within seven days.
The team identified several change ideas, including:
- Starting discharge planning earlier in the patient’s stay
- Creating a new discharge plan called the Transition Care Report: With the help of Osler’s Patient Family Advisory Committee,
the language in the Transition Care Report is easy to understand, the layout
design is patient focused and the electronic document when printed out, allows
the nurse and the patient/caregiver to have a conversation about next steps and
action items that the patient is responsible for, in order to manage their
health condition while living in the community.
This new approach was tested with former patients and the feedback was
positive. The plan is to implement the
new report in June, 2019.
- Ensuring an Osler psychiatrist had one hour of protected time each week to see patients who were not able to schedule an appointment elsewhere following discharge
- Increased use of OTN
documentation of patients' community connections: Nurses in their daily assessment with the patient are
identifying existing connections with health care providers in the community
(e.g. primary care providers, case workers, etc.). These known connections are
captured on the unit’s Whiteboard, and when appropriate are invited to
participate in discharge planning discussions alongside patients, caregivers
and staff that take place on the Unit’s Rapid Rounds. Part of this plan includes details of the
first follow up appointment, scheduled by the unit’s Clerical Associate while
the patient is receiving care on the unit.
communication between in-patient and out-patient Osler programs
View the full project summary here.
Osler achieved significant results and continues to sustain their efforts, and a staff survey showed that the project helped improve employee engagement in addition to the positive patient impacts it produced.
This team is committed to collecting and monitoring key indicators to determine if their changes have made the transition process better for patients, their caregivers and the health system. It’s too early to tell if readmission rates or patient experience data have improved, but some process measures like medication reconciliation and percentage of patients receiving a follow up appointment on discharge are showing favourable results. For example, medication reconciliation is occurring on average 91.6% for all patients prior to discharge.
For more information on this improvement initiative, please contact Tina Smith Krans, Research Analyst in the Mental Health and Addictions Program at William Osler Health System: TINA.SMITHKRANS@williamoslerhs.ca.
How do you support clients with mental health needs? Share your
experiences by clicking on “Add a Comment” below.
This post is part of a series about how quality standards can be used to support quality improvement together with others who are working on adopting the quality standards. The introductory post can be found here.