Coordinated Discharge

Coordinating care for smooth transition at discharge

Improving communication through digital supports

Ensuring attachment to a Health Home

Optimizing home and community care

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Welcome to the Coordinated Discharge Working Group page. We will tell you about why our group was formed, who's involved and what we are working towards.

When people are discharged from the hospital those involved should know what the follow-up care plan is, and with whom and when care will happen. This applies to individuals, families and providers. The current system is not efficient, leading to readmissions and poor care after leaving the hospital. We are working to ensure smooth and coordinated transitions to and from the hospital.

Current challenges

  • Many people do not have the support they need for a smooth transition or recovery after being discharged from one of the three hospitals - Kingston Health Sciences Centre, Lennox & Addington Community General Hospital and Providence Care Hospital

  • Communication among the hospitals and community providers is not always coordinated or consistent

  • Without proper follow up after leaving the hospital, people are at risk of readmission, emergency visits and poor recovery

Who's involved?

Community members, hospital and community health-care providers, home and community care agencies, municipality supports, academics and specialists from across the region are working together.

Community members include people with lived experience of mental health and addictions, family, caregivers, Indigenous and Francophone representatives, 2SLGBTQ+ and others.

View which organizations and FLA OHT partners are in the working group.

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What we are working towards

We are improving how care is coordinated and continued for all individuals leaving any of the three partner hospitals.

We will measure the impact of improved coordination and continuity of care, such as:

  • reduces readmissions to hospital

  • reduces urgent care/emergency room visits

  • improves health and wellness

  • creates positive experience for clients, families and providers

Coordinated discharge projects

There are three main areas we are working on:

  1. Improving the discharge process for people leaving a hospital

  2. Standardizing Patient-Oriented Discharge Summaries

  3. Supporting people to be connected to the appropriate community supports

  • The Care Navigator will work with one Health Home to:

    • help coordinate the care team to support people as they transition to and from hospital and home

    • help people connect to the right health and social services after leaving the hospital

  • A Patient-oriented Discharge Summary template was co-designed by people and health-care providers. The template:

    • is a set of instructions to help people and families know how to manage at home after leaving the hospital

    • is helping people and their caregivers better manage their care at home

    • is being considered by the three partner hospitals and by the Lumeo project team, as they build the regional Health Information System. Learn more about this Digital Support Structure project.

What is a Health Home?

A person's Health Home is where or with whom they have most of their basic or primary health care: a family doctor, nurse practitioner, walk-in clinic, etc.

 

A Health Home may include other health care providers that are part of the circle of care.

PROGRESS UPDATE:

  • The process for coordinating care after discharge was reviewed in early 2022 by a process improvement specialist in collaboration with the partners involved. Recommendations were made. A Care Navigator role was created in a Health Home for a one-year pilot. The Victorian Order of Nurses (VON) offered a team member in-kind for the pilot, which started on September 6, 2022.

Resources

  • Add regional links ?

  • Tools for providers  or patients/clients ?

  • WG report?

  • Articles ?

Help improve the local health care system

Share your ideas or get involved!