E2 - PREVENT - Improving the transition from hospital to home for patients with CHF/COPD (Preventing Readmissions and ER Visits in Elgin through Novel Transitions)

2. Continuous care: ensuring seamless transitions for patients across the continuum of care

  • Date: Friday, September 20, 2019
  • Concurrent Session E

  • Time: 11:00am–11:45am

  • Room: Pier 4
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives

  • Review the challenges of the current discharge process
  • Understand the changes required to improve the discharge process and result in a seamless transition from hospital to community 
  • Discuss the barriers to implementing this model and how they were overcome  

Summary/Abstract

Patients with CHF or COPD are often complex and at high risk of readmission after hospitalization.  The transition from hospital to community may involve numerous providers across multiple organizations and can be difficult for both patients and providers to navigate.  PREVENT utilizes Coordinated Care Planning to facilitate communication among hospital, primary care, and home care providers and improve continuity of care across sectors.  The key component of the PREVENT process is a brief care conference the day prior to discharge.  The care conference consists of a handover from hospital attending physician to community primary care provider, and also includes the patient, their family, and community providers.  Other components of the process include standardized self-management education which is shared with all providers, consistent nursing follow up in the home within 48 hours of discharge, and the prioritization of prompt primary care provider follow up in the community.  By improving the transition process we aim to decrease 30 day readmission rates and ER visits for patients with CHF/COPD.
 

Presenter

  • Connor Cleary, Project Lead, Health Links London Middlesex & Elgin, Thames Valley Family Health Team
  • Dr. Jillian Toogood, Primary Care Physician, East Elgin Family Health Team
  • Dr. Waleed Chehadi, Intensivist and Chief of Staff, St. Thomas Elgin General Hospital
  • Frank Ruberto, Executive Director, Niagara Medical Group FHT

Authors/Contributors

  • Dr. Waleed Chehadi, Chief of Staff and Intensivist, St. Thomas Elgin General Hospital    
  • Dr. Jillian Toogood, Primary Care Physician, East Elgin FHT    
  • Barb Smith, Manager, St. Thomas Elgin General Hospital    
  • Rebecca Sutcliffe, Patient Care Manager, Home and Community Care    
  • Jackie, Primary Care Manager, Central CHC
  • Connor Clearly, Project Lead, Health Links London Middlesex & Elgin, Thames Valley Family Health Team
2019 Concurrent Session