Coordinated teams – no gaps in transitions

Fewer readmissions/ ER/ALC

Supported by digital strategy

Attachment to health homes for all discharges

Having to be a patient in a hospital is often an experience you want to avoid. However, when and if you go the hospital, your experience should feel somewhat familiar and expected along every step of the care journey. Leaving the hospital should be the same. As a patient, we believe that upon discharge from the hospital you should know what your follow up care plan is, who will be following up with you and when that will happen.

Through the Coordinated Discharge working group we are working towards a future where we will have an integrated care navigation model with every People-Centred Health Home by aligning a Care Navigator to support a team-based care approach to support patient transitions to and from hospital and home.
 

As part of this work, all primary care providers will know when their patients go into and out of hospital, are involved in discharge planning and all hospital team care members will understand the patients’ health care story as a result of the relationships they have with the embedded Health Home Care Navigator. This will help create a consistent patient discharge experience among all hospitals in our FLA OHT region.
 

To make this happen, we are doing an environmental scan to help us identify what the current gaps in the system are and what the communication flows need to be to optimize existing processes.