Improving transitions in care is an important priority in
the health care system. To facilitate province-wide improvement on this issue,
a set of indicators related to timely and efficient transitions was included in
the 2019/20 Quality Improvement Plans (QIPs).
We recently held a webinar to share our observations from
the QIPs related to transitions from hospital to primary care. The webinar
introduced the indicators and summarized the work organizations are doing to
improve in this area. Guest speakers from Brockville General Hospital and Leeds-Grenville
Family Health Team also shared their experiences in working to improve
transitions from hospital to primary care.
If you missed the webinar, you can view the recording
or the slide deck, and a summary is presented below.
related to transitions from hospital to primary care
- Medication reconciliation at discharge (hospital)
- Discharge summaries sent to primary care provider
within 48 hours
- Patient experience: Did you receive enough
information on discharge?
- Seven-day post-hospital discharge follow-up (primary care)
organizations doing to improve on these indicators?
Many organizations are using technology to smooth
transitions, using process mapping to guide improvement, and working on role
clarity to ensure the most appropriate person/provider is responsible for specific
steps in the transitions process.
Some organizations are working on these initiatives in
collaboration with partners. This is often necessary as some of this work must
be done outside an organization’s walls.
Here are a few approaches that organizations are using for
reconciliation at discharge and discharge summaries sent to primary care
- Audit and monitoring
- Education and training
- Technology and electronic changes
- Process redesign
Did you receive enough information on discharge?
- Education for staff and patients
- Patient information packages
- Patient-oriented discharge summaries (PODS)
- Revising material in collaboration with patients
- Scheduling follow-up appointments before discharge
post-hospital discharge follow-up
- Enabling electronic notifications
- Receiving discharge summaries (tracking and care
- Scheduling discharge appointments
Spotlight on Brockville
Brockville General Hospital is a medium-sized community
hospital in Southeastern Ontario. Dr Shalini Sharma, Chief of Family Medicine
& Palliative Care; Melissa Berquist, Program Manager, Medical Surgical
Unit; and Jackie Smylie, Manager, Quality and Risk spoke about their work to improve
the discharge process:
- To improve patient experience, they first investigated
their performance on the patient experience indicator and found that patients
wanted more information in writing. To address this gap, they involved charge
nurses in preparing more written info on discharge and created a template for a
medication sheet to be provided to patients.
- To improve sending discharge summaries, they
identified a new role of an admissionist to care for patients being admitted
from the ED. This enabled their hospitalist to focus on preparing patients for
discharge, including through preparing discharge summaries and educating
Spotlight on Leeds-Grenville
Family Health Team
The Leeds-Grenville Family Health Team is located very close
to Brockville General Hospital. Jenny Lane, Executive Director, and Julie
McGlynn, RN, described numerous ways their organization receives information
that one of their patients has been discharged from hospital:
The family health team has developed a process to follow up
with patients after discharge that works for their situation:
- A nurse contacts the patient/family and conducts
triage using a standard set of questions. This data is entered into the
patient’s EMR through a stamp that dates and times the entry.
- Based on the results, the nurse books the
patient for a follow-up appointment and/or refers the patient to services and
programs (e.g., Health Links, pharmacist, community supports). The providers
appreciate having the nurse triage the patients, and the patients are also
thankful that the nurse calls within a few days.
Check out the recording or slide deck for more
details about our observations from the 2019/20 QIPs and how these spotlight
organizations are improving transitions between hospitals and primary care.
If you’ve worked on improving transitions by partnering with
other organizations, we encourage you to share your tips or tools below!
Are you interested in
learning more about transitions from hospital to primary care?
For more change ideas and tools, check out the Indicators
& Change Ideas pages for:
Stay tuned for
upcoming webinars in the Timely & Efficient Transitions Series!
Dates and registration links can be found here: http://bit.ly/QIWebinars