Posts

Health Quality Ontario hosted the latest Quality Rounds Ontario on November 6 ^th, 2019 entitled Transitions Between Hospital and Home: Achieving a Standard of Care . If you missed it, you can watched the archived session here.

As 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, shared 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 hospital.

Below is a summary of the questions posed during the Quality Rounds and responses from Dr. Amir Ginzburg and Dr. Lianne Jeffs.

Was 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?

Yes, this 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.

Based on 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.

Please note 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 the website here. We will include these recommendations in Appendix A of the quality standard soon.

What 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.

Other ways 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.

Also, encouraging 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.

Last 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?

Yes, this 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.

An 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.

Individualized 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.

Does the [comprehensive assessments] part include InterRAI assessments? If so, which ones are best used to support patient transitions?

Yes, the 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: http://health.gov.on.ca/en/public/programs/lhin/do...

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: http://www.interrai.org/contact-assessment.html

Below is a summary of the questions posed during the Quality Rounds and responses from Bonnie Nicholas.

What computer system does Thunder Bay Regional use?

Thunder Bay Regional uses Meditech.

Can you provide examples of your any of the Thunder Bay Regional PODS?

Yes, some examples are for CHF, COPD, and Oncology.

Do you 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.

Are these PODS applied to First Nations people living on-reserve?

Yes, they are.

Given 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.

Who at the hospital is responsible for ensuring the PODS is complete and provided to the patient? Is it nursing? Physicians?

The 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.

We are 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.

Is there a specific nursing role that conducts the discharge follow up call (i.e. charge nurse, NP, transitional care nurse)?

Currently 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.

How were the nurses selected to do the follow-up phone calls? Was it a core group or just whoever was assigned?

Nurses are 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.

Did the PODS exercise require any additional FTEs?

For the in-patient component, we utilized our CNS, and expert allied health, physicians and nurses.

I'm 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?

Though we 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.

Other areas 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.

Where did you see the biggest gains with the Bundled PODS? Inpatient Medicine? Surgery? Adult MHA? Applying a senior friendly lens?

The biggest 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.

Are the 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.

What are some examples of how you made the PODS tool senior friendly?

Please see example. We used large font and simple language.

How do you help improve transitions between hospital and home in your organization? Add a comment below or email KTE@hqontario.ca.