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 continue to work with our regional partners to implement and measure the effectiveness of clear pathways across the entire continuum of care for patients with chronic obstructive pulmonary disease, hip fractures and life-limiting illnesses who require palliative care.

By 2019:

KHSC is fully engaged with our community partners to support patients with complex-acute and chronic conditions


Continue to implement and measure the effectiveness of care pathways for chronic obstructive pulmonary disease, hip fractures and palliative care

How are we doing?

Chronic obstructive pulmonary disease:

In Q2 we launched the acute admission order set for COPD and worked on drafting the critical care ventilated COPD patient order set for the team to review. The discharge order set and inpatient care pathway for the KGH site are in development.

We are on track with our deliverables to meet the target that was set for this fiscal year. A digital order set for COPD admissions has been approved for KHSC and standardized education is being determined.


Hip fractures:

At KHSC an order set for patients presenting with a hip fracture is used consistently, however, there are process differences across the SE LHIN for this patient group. We are collaborating with our regional partners to develop one standardized order set for use across the SE LHIN.

In Q2 the team finalized the transfer of care model, including criteria for transporting patients across sites and working with Criticall Ontario to update a hip fracture agreement.

We are on track to meet the target for this fiscal year. In Q3 a pilot project will be done that will see the  implementation of the order set based on the provincial QBP digital order set and the KHSC pre- and post-surgery order sets.


Palliative care:

A NP-Palliative Care was recruited in July to support Phase 2 of this initiative. Case finding continued in Q2 at 100% of all admissions. Further refinements to the data set were undertaken to make the final data set more efficient for the NP-Palliative Care to quickly scan and triage cases for follow-up.

Case-finding activity continued in Q2. 1,931 KGH admissions were screened July 1st – August 10th. Results for Q2 indicate:

  1. 180 (9.32%) patients met one or more of the pathway triggers and would benefit from palliative care, 84.52% of admission did not.
  2. 59 (3.06%) patients identified with “other advanced life limiting illness” but that are out of scope for the designed pathways (unintended outcome and of benefit to KHSC future pathway work).
  3. 60 (3.11%) cases flagged as ‘unsure’ and are under review by a Palliative Care physician