Theme 7. Clinical innovations keeping people at home and out of the hospital
Presentation Materials (Members only)
Learning Objectives
Attendees will:
- Understand the benefits from hospital and primary care perspectives of working together to address hospital readmissions versus working in silos
- Explain how care transitions impacts avoidable and unavoidable readmissions for populations at risk
- Understand why COPD /CHF populations were targeted
- Discuss how hospital utilization data informed the initiation of improvement activity
- Describe tests of change undertaken by each organization and in collaboration
- Discuss expected outcomes, system gaps and current mitigation strategies.
Summary
To respond to a growing readmission rates and hospital length of stay for COPD and CHF populations, Guelph General Hospital (GGH) implemented clinical pathways to ensure best practice. A key intervention in the clinical pathway was to establish a follow up appointment with primary care, for the patient prior to discharge. This intervention was implemented via a fax to provider’s office. Collaboration between GGH and GFHT was initiated to explore the uptake and rates of scheduled appointments received before patients were discharged. This initiative resulted in the following changes:
- Primary care involvement in hospital discharge planning (including where needed, phone calls from the charge nurse to discuss patient discharge needs)
- Primary care calling patients at risk of readmission within 48 hours post hospital discharge
- Shared lists of practice based primary care contacts to facilitate scheduled telephone appointments prior to discharge
- Electronic notification of primary provider of hospital patient admission and or discharge to facilitate patient centred and effective transition planning
- Regular collaborative meetings to explore what is working well and what needs to be improved
Our test efforts have occurred within three pilot practices within the Guelph Family Health Team. Regular practice team meetings with the QI facilitator to review team improvement progress. Lessons learned will be integrated shared and tested for implementation across all practices.
Presenters
- Guelph FHT
- Tricia Wilkerson, Director, Quality and Evaluation
- Sylvia Scott, Director, Clinical and Professional Services
- Jackie Beaton, Inpatient Flow Coordinator, Guelph General Hospital
Authors and Contributors
- Laurie Williamson, R.N., BScN, Clinical Educator Ambulatory Care/Clinical Pathway Coordinator, Guelph General Hospital