North Lambton Community Health Centre (NLCHC) is positively impacting Alternate Level of Care (ALC) by bringing a health equity lens to this issue, and collaborating with community partners and their local hospital.
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.
To learn more about their ALC approach, Health Quality Ontario had a chance to catch up with Kathy Bresett, Executive Director and Leah Willemse, Quality and Chronic Disease Team Lead at NLCHC.
Can you describe the strategies you use to improve patients’ journeys through the health care system?
There are four initiatives we are focused on to improve transitions in care:
Working from a health equity lens
Health equity is one of our organization’s strategic goals and the underpinning to all our work. Most of our most complex patients are impacted by the social determinants of health, which can further impact their transitions through the health care system.
We have been involved in a research project with the University of British Columbia called EQUIP Health Care that has been studying interventions aimed at equipping health care providers with equity-oriented tools. There is a toolkit, modules and several resources on the EQUIP website about equity-oriented care.
The project has helped us with organizational and staff development to improve care for the people we serve. We have trained staff, board members and our volunteers on health equity practice.
Before we started to focus on health equity, we felt stuck. Now we feel like we’re starting to shift the un-shiftable by using a health equity lens to drive our work.
We also hosted a Health Equity Symposium that provided a forum for disseminating information in the EQUIP toolkit and showcasing local health equity initiatives. We’re planning an addictions event in the fall that will help build capacity for our Health Links. The goal of these events is to increase capacity among our partners to help support complex and vulnerable patients.
Speakers at the Health Equity Symposium: Organizations include: Bluewater Health, Grand Bend and Area Community Health Centre, Faten Mitchell Consulting, VON Sarnia-Lambton, North Lambton CHC, Erie St. Clair LHIN, Health Quality Ontario, Lambton Public Health, Arthur Labatt Family School of Nursing Western University
Participation in the Health Quality Partners of Sarnia-Lambton Committee
The Health Quality Partners of Sarnia-Lambton Committee brings together over 20 health and social service partners across the sub-region and a Bluewater Health (our local hospital) Patient Experience Partner to identify system gaps and brainstorm collaborative solutions to improve the patient journey during transitions in care. The group first brought together primary care organizations and then grew to include other partners such as our LHIN and social service partners like EMS.
At each meeting, we showcase one community partner and their role in the health care system so that we can develop a solid understanding of each other’s services. This certainly takes time, but we are seeing the benefits of this relationship-building with the goal of creating alignment to fill gaps for patients.
The committee is co-chaired by a local hospital representative and a representative from a community health agency. Having representation from our local hospital helps increase awareness of the barriers patients face when they return home and the services they need in the community.
Our CHC and other organizations are also invited to a quarterly review of hospital metrics, which include ALC. These meetings allow us to have robust discussions about what primary care can offer the health care system.
One area we are focusing on is improving transitions for patients with Chronic Obstructive Pulmonary Disease (COPD), among other populations. We’ve identified a common QIP indicator we can work towards and are developing a collaborative work plan. The collaborative meets bi-monthly to review strategies to improve transitions for this population through a collaborative cross-sector approach. This group is working towards identifying COPD patients who would benefit from the Health Links approach in-hospital and connected to a case manager. The goal is for the case manager to help ensure they are connected to a pulmonary rehab program in the community.
Implementation of a new integrated position between Bluewater Health and Lambton County Lake Huron Health Links
We approached our local hospital, Bluewater Health, with the idea to create a new position to support patients’ transitions from the hospital to home/primary care. Funding and accountability for the position is shared between NLCHC and the hospital.
The position is housed in the hospital and she works with the complex discharge manager to identify Health Links referrals. She also works closely with the LHIN Home and Community Care Coordinator to ensure appropriate supports are put in place in the community.
Use of technology to track patient transitions
Currently, NLCHC is manually tracking patients on a spreadsheet as they move through the system.In the future, we’ll be implementing the South East Health Integrated Information Portal (SHIIP) which is used in Erie-St. Clair LHIN. Another technology enhancement that will support our initiatives is our new Electronic Medical Record (EMR).
Once these systems are in place, NLCHC will have access to real time data and be able to track referrals and trends and run reports.
Do you have other ALC initiatives you’re working on?
Yes. Two Nurse Practitioners attend rounds bi-weekly at an assisted living facility in Kettle and Stony Point First Nation.Attendance at the rounds helps to provide the medical management required to keep people out of hospital.The frequent nature of these rounds speaks to the complexity and needs of these patients. Without this care, it’s likely that these patients may end up in-hospital.
Other work being done to support ALC avoidance is participation in early nursing home planning in collaboration with LHIN Home and Community Care.
What advice do you have for other primary care organizations working on the ALC issue?
Primary care organizations should not limit their potential impact on the ALC issue. If we keep doing the same old thing, we’ll keep getting the same results.
It’s important to work with your community partners and be at the table to make a collective impact. We are working more with our local hospital and they are keen to learn how primary care can help improve the ALC issue.
You may also be interested in: Improving ALC through Partnership: Spotlight on North Hamilton CHC
Do you work on the issue of ALC at your organization? Reach out to Leah Willemseon Quorum or add your questions or comments below.