managing transitionshssontario.ca/who/documents/tp06_managingsystemstransitions.… · leading...

Managing Transitions: A Seamless System that is Simple to Navigate

OACCAC Conference

June 20, 2013

Michelle Samm

Senior Project Manager

http://trilliumhealthpartners.ca/

http://www.haltonhealthcare.on.ca/

1 Integrated Hospital Transitions Project

Transitions of Care

A set of actions designed to ensure the

coordination and continuity of care

as patients transfer between different

locations or different levels of care in

the same location

Coleman, E.A. Berenson, R.A. Lost in Transition: Challenges and Opportunities

for Improving the Quality of Transitional Care Ann Intern Med 2004; 140:533-36


Mississauga Halton LHIN

• History of successful implementation of

innovative strategies

• Increased focus on providing care in the

community

• Strong community sector

4 3 Integrated Hospital Transitions Project

Patients/Caregivers Experience


....system-level transformation is required to meet the needs of MH LHIN

residents


To achieve transformational change

through a single point of

accountability for hospital transitions


Our Goal

System-Level Benefits

•Increase in client/patient/family satisfaction through seamless transitions and enhanced

engagement in their care

•Decrease in ED visits and readmission rates through enhanced transition planning and follow-up

care

•Reduction in LOS through timely discharges

•Decrease in ALC by promoting timely notifications


Our Journey

Current State

Leading Practice

Principles &

Philosophy

Future State


Phase 1

Current State Approach


Interviews

&

Focus Groups

Document

Review

Data

Analysis

Current State Findings


• Process is fragmented

• Inadequate timeliness and

quality of information

• Insufficient collaboration,

cooperation and communication

• Multiple assessments, duplication

and repetition

• Discharge process is confusing

System Level Opportunities for Improvement


Leading Practice Approach

Successful models were identified from

leading jurisdictions, based on the

following criteria:

• Relevance

• Coordination

• Improvement


Leading Organizations Examined

Massachusetts State Quality Improvement

Institute


http://www.adrc-tae.acl.gov/tiki-index.php?page=HomePage

Leading Practice Findings

• A shared vision defining the ideal state for transitions

1. Shared Vision

• Common principles that capture values and priorities

2. Common Principles

• Defined roles and expectations for the “sending team,” “receiving team,” and the patient/family

3. Defined Accountabilities

4. Core Components


• Core components (processes, activities, and tools) that comprise the transition model

Future State Approach


Current

State

Leading

Practice

Integrated

Transition Model

1. Our Shared Vision


Safe, effective, timely care during transitions between and within settings of care

2. Our Principles

Client/Patient

Centered

Safe

Equitable

Dynamic

Effective

Timely

Efficient


3. Accountability

Integrated Leadership Team


4. Core Components


Assess

Plan

Empower

Support

Our Model

Pre Discharge Post Discharge

Assess for Needs

Plan for Transitions

Empower Client/Patient/Families

Support for Transition


Continuum of Care

Se

am

less

, C

om

pre

he

nsi

ve

Ca

re

Assess

Standardized assessments that is supported by a

common tool and enables

patient stratification based on

post discharge needs

Empower

Early planning is enabled by collective access to

information and supported by

standardize tools

Plan

Clients/patients are

educated and empowered

through a comprehensive

array of tools and resources

Support

Continuity of care is extended

through smart feedback

loops linked to the

appropriate tools and

resources

IHTM

22

Key Assumptions

• System level

• Design

• Operational


Key Learnings

June 28, 2013 24 Integrated Hospital Transitions Project

Next Steps



Initiative # 1

Initiative #2

Initiative #3

Initiative #4

Initiative #5

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