What's Your Story?

This is part of the Health Council of Canada’s engagement with Canadians, health care stakeholders and governments who are working toward strengthening our health care system. Attendees at the 2010 National Healthcare Leadership Conference this year in Winnipeg, Manitoba were invited to submit entries to our Tell Us Your Success Story (now called What’s Your Story?) poll. We wanted to hear inspiring stories of best practices and innovation that have led to better outcomes for clients/patients and/or for the health system in general.

The following What’s Your Story? Submission came from Ms. Susan Bisaillon, Executive Director for Clinical Operations at the Trillium Health Centre in Mississauga, Ontario. It describes a project designed to tackle a specific problem related to the shifting care needs of elderly patients within the local health care system. The Health Council interviewed Ms. Bisaillon to find out more about how the centre was able to achieve such change, transforming its operation and discharge processes into an award-winning leading practice. Next month, the Health Council will produce a podcast of this story for Canadians visiting us at www.healthcouncilcanada.ca.

Q. Can you describe the specific challenge you and your colleagues at the Trillium Health Centre were facing?

A. In March, 2009, the number of Alternate Levels of Care (ALC)* cases in our facility peaked at 131, representing 18% of the hospital’s beds. These high ALC rates created Emergency Room gridlock, blocking patient access to acute care beds. Trillium was struggling to flow admitted patients out of the ER as the number of ALC cases increased. Emergency waits were very long and the Mississauga-Halton Local Health Integration Network (LHIN) challenged us—along with our Community Care Access Centre (CCAC) partner—to create innovative changes. The goal was to reduce ALC pressures to improve our emergency wait times.

* When a patient is occupying a bed in a hospital and does not require the intensity of resources/services provided in the specific care setting, the patient must be designated Alternate Level of Care (ALC) at that time by the physician or her/his delegate. The ALC wait period starts at the time of designation and ends at the time of discharge/transfer to a discharge destination (or when the patient’s needs or condition changes and the designation of ALC no longer applies).

Q. How did you approach the problem?

A. In addressing the complex problem of ALC pressures, we realized it was important to move forward with the support of partners—in this case, with our LHIN and the Mississauga-Halton CCAC.

First, we were able to obtain consensus on a number of underlying issues contributing to long waits in ER, including the complexities around our ALC cases and opportunities for leveraging funding sources that already existed.

One of our strategies was to utilize a Lean consultant to identify the non-value-added or “waste” in our process. We aimed to clarify roles within the current system in order to develop more accountable and collaborative discharge processes. This included expediting the transition of acute care patients back into appropriate community settings.

We were able to do this by leveraging community capacity expansions that were funded by the Mississauga-Halton LHIN “Aging at Home” initiative from the Ontario Ministry of Health and Long-Term Care.

Q. Were these efforts successful?

A. In just over 12 months, we were able to achieve a 67% reduction in our ALC cases, bringing the proportion of ALC patients down to 7% of our inpatient beds. And we experienced positive satisfaction from our patients and staff as a result of this change.

Q. What were some of the changes in practices and protocols that you made in order to improve the discharge processes?

A. We were able to create a sense of urgency—what’s known as a “burning platform”—which encouraged everyone to fully engage in this important work. Individuals were seconded to focus attention on achieving traction and movement on the work needed. We learned that we needed to:

• create a one-team approach with the CCAC partners, which meant establishing a Joint Discharge Operation group where Trillium’s discharge planning staff and the Mississauga-Halton CCAC case managers worked together;
• segment the ALC patients into manageable streams such as “home first”, chronic, chronic palliative and rehabilitation;
• hold daily review sessions to ensure that any new information about the patient was communicated and acted upon immediately;
• establish key protocols contributing to “Home First,” an initiative in the Mississauga-Halton LHIN that aims to have patients who are admitted to hospitals return home immediately after discharge from acute care;
• revamp our Information Technology (IT) functions;
• tighten the approval process for placement on the ALC long-term care list; and
• introduce the role of Patient Navigator to assist with discharge planning.

Q. What kind of support did you give to the patients returning home after discharge from the hospital?

We ensured that these patients received full assessment and review by Trillium and the Mississauga-Halton CCAC. This enabled all necessary supports to be implemented in the right care environment to support safe post-discharge care. Successful implementation depended on getting physicians on board with a consistent message about having the patient go home first—before being placed in long-term care.

Furthermore, we introduced IT solutions with software (Medworxx) that measures utilization to determine more accurately when a patient needed to be deemed ALC or ready for discharge. We are now one of the six ALC beta testing sites for the province of Ontario, which is piloting new software for ALC with Cancer Care Ontario’s Wait Times Information System (WTIS).

Q. In hindsight, what did you learn from this successful effort that might be of use to colleagues in other areas of the health care system?

A. Translating the “Home First” changes into practices with Trillium and our regional CCAC was challenging at first, but we were able to make it work. It continues to be a journey that we work on and sustain on a daily basis.

What we have seen is that it’s all about getting the patient to the right placement and continuing to give the support that is needed. It was a significant change for our organization and the Mississauga-Halton CCAC that affected how we worked together. The CCAC and Trillium had to change their focus. This was an interesting project for us to work on. We were very fortunate that everyone stepped up and got on board to do what we could to make the situation better.

Also, it was a change internally for our staff because we had to redefine the roles and responsibilities of everyone involved in discharge planning at the Centre. We redesigned the roles and responsibilities around discharge planning and placement, and there was a significant change in management process with respect to roles and accountabilities.

Q. What is your big “take away” message for others?

A. You can have the investment—that is, both the funding and the human resources— but if you do not have the desire and commitment to do what is best for the patients, the change will not happen.

Q. What are the next steps for Trillium?

A. Trillium will continue to refine its protocols and roles and procedures related to discharge practices for ALC patients, while working closely with the Mississauga-Halton CCAC to improve all aspects of this transition. We will also seize opportunities to enhance the partnership with the LHIN.

We continue to discuss the challenges associated with hard-to-serve/hard-to-please patients and have created protocols and documents to assist Trillium and CCAC staff in handling these cases. Tools were also developed for staff, patients and families to facilitate a safe and timely discharge to the most appropriate placement.

Background
The Trillium Health Centre is a large academic-affiliated hospital within the Mississauga-Halton Local Health Integration Network (LHIN) that serves an area of over one million residents. The hospital serves as a regional centre for advanced cardiac and neuroscience, including stroke and vascular care, and provides specialized services in dealing with sexual assault and domestic violence.