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 third quarter (Q3), October to December, we received approval from SECHEF to proceed with the regional care pathways that will ensure supports are in place for the patients once discharged. We revised our original proposal to incorporate the Inspire Program as it is a community based program.  Moving forward with the revised plan we are focused on how to build relationships to manage and support chronic obstructive pulmonary disease (COPD) patients in the community across the SE LHIN with the objective of decreasing admissions. Regarding hip fractures, we met with regional stakeholders to establish an approach to move forward with the top three priorities, deliberate on the feasibility of the approach, and identify possible barriers to delivering on the strategy. The selected top three priorities are: time to surgery, rehabilitation alignment and hip fracture navigation. These will be focused on in the coming months.

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. This year, we are aiming to create a comprehensive, well coordinated palliative care program for patients, families and care providers. This quarter, we developed draft care pathways for oncology, renal, respirology and cardiology programs. We met in December with clinical leads from the four clinical areas and palliative medicine to review the pathways and determine next steps and action items. Next quarter, we will begin implementation planning while continuing to engage with clinical stakeholders to refine the pathways. As part of the implementation, we will also develop a measurement plan 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. This year we are aiming to implement the 'teach back' system, which provides members of the care team with the tools to improve health literacy through patient centred communication. This quarter, we introduced the topic of health literacy in the chronic kidney disease (CKD) program and discussed how to introduce the concept in the pre dialysis clinic. At the same time, KGH was accepted as a partner site with University Health Network (UHN) to implement an ARTIC funded Patient Oriented Discharge Summary (PODS). As a result, we have shifted the focus of this tactic to incorporate the entire medicine program in the rollout of PODS. This is a innovative discharge communication tool that meets the health literacy needs of patients and their families and includes our teach back method as a component. While this shifts the timeline of our Health Literacy tactic plan, it actually strengthens KGH's position as a health literate organization by reaching a wider audience, more quickly with an important health literacy tool.  Next quarter, we will begin to work with UHN on the implementation of the Patient Oriented Discharge Summary and associated staff education about the teach back method. While this is taking place, occupational health students will continue the work in the pre dialysis clinic to obtain baseline data on the state of health literacy awareness amongst health care providers and health literacy in the CKD patient and family population.


Yes, we are on track to deliver on all our planned milestones with a revision to our Health Literacy tactic plans for Q4 to take advantage of the ARTIC funded project opportunity.