4. Create seamless transitions in care for patients across our regional health-care system

The care patients receive while in hospital is typically excellent. However, patients who require different levels of care over an extended period of time in multiple settings often have trouble receiving care across different parts of the health system and at transition points. Communication can be difficult, wait times can be long and patients and families can feel like they are 'falling through  cracks' in the system. This year, we will work with our regional partners to implement clear pathways across the entire continuum of care for patients with chronic obstructive pulmonary disease, hip fractures and patients with life-limiting illnesses who require palliative care.

By 2018:

Patient navigation pathways and partnerships are established for complex-acute and chronic patient populations

In 2016-17 we will:

Implement continuum of care pathways for chronic obstructive pulmonary disease, hip fractures and palliative care

How are we doing?

As of our second quarter (Q2), July to September, we are awaiting approval from the South East LHIN CCAC & Hospital Executive Forum (SECHEF) on our recommendations to proceed with region-wide implementation of regional best practice care pathways for patients presenting with chronic obstructive pulmonary disease (COPD) and patients presenting with hip fractures. In the meantime, we have implemented the KGH elements of each patient pathway as well as the accompanying order sets so that we are prepared to proceed with regional implementation once SECHEF provides approval, which we anticipate to happen in Q3.  At that point, we will re-engage stakeholders to review the proposed care pathways, as well as the accompanying order sets and discharge checklists. 

Patients with life-limiting illness who receive appropriate and early palliative care not only have improved quality of life, their family members cope better, they have less need for hospital care and they are more likely to die in their place of choice. Through consultation with stakeholders we have developed a plan and performance management framework for an enhanced palliative care program at KGH. Working with stakeholders in the oncology, renal, respirology and cardiology programs we have begun to map out draft palliative care pathways for their patient populations. Each of these programs has been tasked with engaging their own teams to review and further develop their pathways in Q3, facilitated by the palliative care project lead, with an eye to finalizing the pathways by the end of the fiscal year and identifying opportunities to test-pilot the pathways for implementation in Q4. Next quarter, we will also begin to develop a performance management framework with clinical process and outcome indicators that we will monitor and report in fiscal 2018. 

Health literacy refers to a broad set of skills that help patients and their families understand health information, participate in self-management and navigate the complex health care system. As part of our aim to implement the 'teach-back' system, which provides members of the care team with the tools to improve health literacy through patient-centred communication, we developed a work plan and communication plan to support the roll out of the teach-back system with the chronic kidney disease (CKD) patient population. In Q2, we developed an education plan that introduces the concept of health literacy and the 'teach-back' method that can be specialized to individual programs in the hospital based on the unique needs of different patient populations. Next quarter, we will start engaging care providers in the chronic kidney disease program to introduce health literacy and the teach-back method. Our education plan will be customized for CKD care providers. It will equip them with the tools to ensure their patients understand their care plans and are empowered to participate in shared decision making about their current and future care. We will also begin developing a plain language dictionary to translate complex medical terms into language that is easily understood by patients. 


Yes, we are on track to deliver on all our planned milestones.