Quality Ontario hosted the latest Quality Rounds Ontario on November 6
Transitions Between Hospital and Home: Achieving a Standard of
. If you missed it, you can watched the archived session here.
co-chairs of the recently released
Transitions Between Hospital and Home quality
standard, Dr. Amir Ginzburg, Chief and Medical Director, Medicine Program,
Trillium Health Partners, and Dr. Lianne Jeffs, Research and Innovation Lead
and Scholar in Residence, Sinai Health System and Nursing and Health
Disciplines Senior Clinician Scientist, Lunenfeld-Tanenbaum Research Institute,
presented the latest
evidence to make the
transition between hospital and home easier for patients and their families.
Bonnie Nicholas, Patient and Family Centred Care
Lead, Patient Experience, Engagement & Advocacy, Thunder Bay Regional
Health Sciences Centre,
her experience in implementing Patient Oriented Discharge Summaries (PODS) – a
proven tool to help patients know how to manage at home when they leave the
Below is a
summary of the questions posed during the Quality Rounds and responses from Dr.
Amir Ginzburg and Dr. Lianne Jeffs.
there any discussion during the development of this quality standard on how
information sharing should be managed? If electronically, how can we develop
compatibility of sharing platforms?
was identified as a system-level barrier throughout our engagement with
stakeholders and the advisory committee. We heard that awareness, uptake, and
integration of digital health solutions, electronic information-sharing
systems, and clinical viewers is not consistent across the province, which may
contribute to inefficient or less-than-ideal ways of sharing patient
information (e.g., fax machines). It was recognized that there is an immediate
need to develop, improve, and strengthen information-sharing among hospitals,
primary care, and applicable home and community care providers.
what we heard from stakeholders and the advisory committee, we have added a
system level recommendation to address this barrier. In summary, the
recommendation addresses the need to improve digital access to integrated
health information to ensure that accurate, complete, and current information
is accessible by patients, caregivers, and health care providers in all care
settings. Updating the PHIPA legislation is one way this may be achieved.
that we have not released these recommendations in the updated draft version of
the Transitions Between Hospital and Home Quality Standard that is currently on
here. We will include these recommendations in
Appendix A of the quality standard soon.
advice do you have to engage physicians in the discharge process so that they
have an opportunity to provide information/input into the discharge plan?
It would be
helpful to assess the current discharge/transition planning process at your organization
and understand the barriers that may impact physician involvement in discharge/transition
planning. Based on our focus groups with front line care providers, we’ve heard
that high caseloads, lack of time, and limited knowledge about engaging
patients and caregivers are some of the barriers that impact discharge
planning. Based on the identified barriers, it may be necessary to modify
current discharge processes to encourage greater physician input into the
discharge plan. For example, interprofessional rounds that include early discussions
with the team on transition planning, sharing transition plans via electronic
systems, or implementing tools such as PODS may enable greater physician
involvement in discharge planning.
to increase knowledge and awareness of transition planning include learning
modules within the curriculum of medicine and continuing medical professional
development, residency and credentialing programs to strengthen knowledge and
skills in developing transitions plans.
physicians as part of their training to spend time observing care in the home
and community. For example, a physician can attend home care visits or primary
care visits to better understand the experience of patient/caregivers/home and
community care providers/primary care. They can see how a transition plan
informs care, see good and bad transition plans and how this impacts patients/caregivers
and health care providers in primary care the home and community.
minute discharges generally mean poor discharge planning. Was there any
discussion in the development of this quality standard about ways in which last
minute discharges can be prevented?
was identified as a problem and it is addressed in Quality Statement 2: Comprehensive
Assessment – transition planning needs to be started early upon admission and
those at high risk for a complex transition need to be identified.
individualized assessment of a person’s current and evolving health care and
social support needs started early upon the person’s admission to hospital by
the interprofessional team can help to anticipate any post-hospital health care
needs or social support needs the person may have and to establish an initial
transitions plan. If comprehensive assessments are not done upon admission, or
if individual assessments are not used to inform their transition plans, this
can result in the patient having a longer hospital stay, unnecessary
readmissions, and a poorer experience.
comprehensive assessments help health care providers identify people who may be
at risk, coordinate health and social support services for those who need them
and develop long-term plans to manage patients’ transition needs.
[comprehensive assessments] part include InterRAI assessments? If so, which
ones are best used to support patient transitions?
InterRAI assessment tools were identified through engagement with stakeholders
and through environmental scans (e.g., provincial home care report – Thriving
at home, see reference below) that can inform and guide comprehensive care and
service planning. These resources/tools are referenced in Quality Statement 9:
Appropriate and Timely Support for Home and Community Care, within the
definitions of terms used in the quality statement - “Assessed for home care
and community support service needs.”
Ministry of Health and Long-Term Care. Thriving
at home: a levels of care framework to improve the quality and consistency of
home and community care for Ontarians [Internet]. Toronto (ON): Queen's Printer
for Ontario; 2017 [cited 2019 Feb]. Available from:
InterRAI, Ministry of Health and Long-Term
Care. Contact assessment (CA): a screening level assessment for emergency
department and intake from community/hospital [Internet]. Toronto (ON): Queen's
Printer for Ontario; 2019 [cited 2019 Mar 8]. Available from:
Below is a
summary of the questions posed during the Quality Rounds and responses from Bonnie
computer system does Thunder Bay Regional use?
Regional uses Meditech.
provide examples of your any of the Thunder Bay Regional PODS?
examples are for
CHF, COPD, and Oncology.
have a serious illness or palliative care PODS?
We do not
have a specific palliative care Patient Oriented Discharge Summary, but we do
have a detailed Cancer PODS.
these PODS applied to First Nations people living on-reserve?
the high Indigenous population around Thunder Bay, has there been any work done
to improve transitions from hospital to home on reserve?
Yes. On our
PODS we have included an area to remind the discharge team to connect with the nurse’s
station on reserve and to ensure supplies/care needs are prepared. We also
engage our Indigenous Navigators to assist our Indigenous patients with any
needs – travel, funding etc.
the hospital is responsible for ensuring the PODS is complete and provided to
the patient? Is it nursing? Physicians?
completion of a PODS is indicated on the electronic order-set for a specific
disease, which is completed by the physician. Nurses complete and review with
the patient to ensure understanding of the information and instructions. The
patient and nurse both sign the PODS. The original is given to the patient and
a copy is kept with the medical record.
currently in evaluation phase to look at how we can utilize the PODS earlier in
the admission to be used as a teaching tool throughout their stay.
a specific nursing role that conducts the discharge follow up call (i.e. charge
nurse, NP, transitional care nurse)?
we train nurses that have experience and are on modified duty to conduct the
discharge follow-up. There is a centralized hub within PFCC, Patient
Experience, Engagement & Advocacy department that facilitates this process.
the nurses selected to do the follow-up phone calls? Was it a core group or
just whoever was assigned?
selected based on knowledge, experience and skill set that are on modified
duties. They are specially trained to interview, triage and provide interventions
within their scope of practice.
PODS exercise require any additional FTEs?
in-patient component, we utilized our CNS, and expert allied health, physicians
curious whether you have insight into why the other areas of the hospital did
not see the same uptake in use of PODS like what was seen in medicine?
started with the Artic Project in 2017 – there was a delay for implementation.
We initiated the PODs on Medicine first to support patient re-admissions, thus
COPD and CHF. We utilized data analysis to support this decision. Medicine was the
first area to incorporate adoption of the PODS, so that is where we have been
able to evaluate the effectiveness of the tool.
within the organization have also recently implemented PODS, – all surgical
areas, adult mental health, and paediatrics and will have an evaluation planned
in the future. Outpatient areas are also looking at developing of a PODS tool
for their patients e.g. Diagnostic imaging, Emergency, etc.
did you see the biggest gains with the Bundled PODS? Inpatient Medicine? Surgery?
Adult MHA? Applying a senior friendly lens?
gain we have seen to date is with our complex medical patients, bundling with
teach-back and the post discharge follow-up call to ensure understanding.
Implementation of the PODS in the other areas are too early for analysis.
PODS forms manual or do they 'live' in your EMR?
To start, they
were developed in paper format. The chart copy is scanned in and saved as part
of the chart through medical records. We will be looking to transition to an
electronic version in the future.
some examples of how you made the PODS tool senior friendly?
Please see example. We used large font and simple language.
you help improve transitions between hospital and home in your organization?
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