Returning home after cardiac surgery can be daunting for patients and families. Without a community support system after discharge, many patients end up coming back to the emergency room for answers and some end up being readmitted to the hospital.
Trillium Health Partners (THP) https://trilliumhealthpartners.ca was recently chosen by the Ontario Ministry of Health and Long-Term Care as one of six pilot projects to help patients transition from hospital to home. THP partnered with Saint Elizabeth Health Care www.saintelizabeth.com, a national organization to provide a full range of integrated care services in the home and in the community.
This new approach known as “Putting Patients at the Heart” (PPATH) is using extensive patient and provider feedback. The partnership enables an Integrated Care Coordinator (ICC) to bring the hospital and home care teams together to jointly develop the post-discharge care plan for the patient.
Technology developed with information services at THP, helps the partnership to work for both patients and providers. The teams at both Saint Elizabeth and THP have access to a single electronic record for each patient using a specially-designed dashboard where they can view real-time information and track patients across the continuum of care.
Saint Elizabeth nurses can also consult with THP’s cardiac team from the patient’s home using secure phones and tablets. PPATH has also established a 24/7 phone line monitored by care coordinators allowing patients to address their questions and concerns without visiting the emergency department.
If necessary, the care coordinator can send a Saint Elizabeth nurse to the patient’s home for an assessment and then recommend further action if needed. For example, when a patient after cardiac surgery developed a high fever, she called the 24 hour phone line and the coordinator immediately arranged for a Saint Elizabeth nurse to visit the patient’s home.
The nurse sent a photo of the patient’s incision to THP, where a surgeon confirmed a potentially significant wound complication and sent a prescription to the pharmacy. The patient visited the cardiac ambulatory clinic the next day to see the surgeon for additional follow-up.
PPATH was launched in February 2016 and early data shows a reduced length of stay for patients of two days, a significant reduction in post-discharge emergency room visits, as well as positive patient and care provider feedback. Within the first three months, 155 cardiac surgery patients were registered with PPATH.
Additional tools such as new patient education methods and tele-monitoring will be rolled out over the coming months as PPATH scales up and builds capacity. According to Elena Holt, Program Director, Cardiac Health for THP, “The goal is to also expand the model not only within cardiac surgery but throughout other hospital programs, the community, and beyond.”