The Partnership Payoff: More Collaborative Patient Care

Osler is working hard to build strong relationships with our partners at the Central West CCAC and Headwaters, as well as primary care providers in the community, to create a more seamless experience for patients as they move across our local health care system. Here are just a few examples of how we work with our partners to close information gaps to improve care.

Hospital to Home

I’ve written before about our regional Hospital to Home (H2H) and the positive impacts it’s having on patients in the community. Since the program began eight months ago, H2H nurses have conducted more than 3,100 visits to nearly 450 patients. Not only has H2H had a positive impact on patients, the program has helped to improve admission and readmission rates at the hospital:

  • Average length of stay for admitted patients was reduced by 3 days
  • Readmission rates have decreased from 11.5 per cent to 9.2 per cent
  • Hospital admissions have been reduced from 21.4 per cent to 13.8 per cent

Another benefit of the program is that H2H nurses are able to access a patient’s electronic health care record when they are in the hospital and in the home so they can ensure continuity of care.

We captured one patient’s experience moving through this program in a new video. See how an integrated nursing team is helping to improve information sharing and creating smoother transitions between points of care.

Telehomecare

In 2013, Osler became host of the Ontario Telemedicine Network’s (OTN) Telehomecare program for the Central West region. This program helps patients living with Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure take control of their health from home using technology. Each patient works with a dedicated Telehomecare nurse who monitors their health and provides coaching to help them learn to manage their condition.

Throughout the six-month program, Telehomecare nurses provide reports to a patient’s primary care provider to ensure they are aware of a patient’s progress and can help inform care plans when there is a change in condition. This collaborative approach involves the patient, nurse and primary care provider to ensure that the best possible outcome is achieved.

Nearly 3,500 patients have participated in this program since it began and the benefits are clear. Patients enrolled in the program saw significant reductions in hospital admissions and fewer visits to the emergency department. See how Telehomecare is benefiting patients in our region:

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How Central West CCAC, Headwaters and Osler are taking patients from Hospital to Home

When patients return home from the hospital, they sometimes need a little bit of extra support. Osler is working with its partners at the Central West Community Care Access Centre (CCAC) and Headwaters Health Care Centre (Headwaters) – as well as the Ontario Telemedicine Network (OTN) and the Central West Local Health Integrated Network (LHIN) – to meet this need with Hospital to Home (H2H).

H2H is an innovative new model of care that is helping to improve clinical handoffs and information sharing when patients leave hospital and re-enter the community. This means that patients continue to receive short-term nursing care from the same team after they return home. H2H will initially support patients with cellulitis and urinary tract infections requiring short-term nursing interventions, later expanding to support those with more complex needs.

Last week, H2H launched at Brampton Civic Hospital. The program originally launched at Etobicoke General Hospital in December and then at Headwaters in January.

Once fully implemented, H2H will help prevent unnecessary hospital admissions, shorten the length of stay for admitted patients, provide greater continuity of care and ultimately, enhance the patient experience for those we serve.

As one of six integrated programs sponsored by the Ministry of Health and Long-Term Care’s new bundled funding model, H2H is an excellent example of how different organizations from across the continuum of care can work together to improve access to care that truly benefits patients. And it’s proving to be effective. Since November 2015, more than 135 patients have been enrolled in the program and dedicated H2H nurses have completed over 750 nursing visits in the community.

With each phase of the H2H rollout, the project team gathered feedback from staff and patients to help shape the program even further. Feedback to date has been very positive. Here’s what some H2H patients had to say:

  • I received outstanding care!”
  • My experience was fantastic. Each Nurse was extremely knowledgeable and they arrived in the timeframe as promised.”
  • “I really appreciate this program. You took the time to talk with my wife and comfort her when I did not know what to say to make her feel better.”
  • “You hired the best nurses for the job. They have all been wonderful!

This kind of patient experience is what we strive to achieve. That we are hearing such overwhelmingly positive feedback so early in the life of the program is a wonderful testament to the team’s commitment to providing patient-inspired care!

What Osler’s Mission, Vision and Values Means to Me

Every month, I have the opportunity to meet with frontline staff for an informal chat and a light meal as part of my Lunch with the President series. This gives me a chance to hear what’s on the minds of staff first-hand while they get to ask me about whatever they want – carte blanche.

And no question is off the table. I’ve been asked about everything from my age to my favourite colour and everything in between. I often get a question that really makes me stop and think. At a recent session, one of the attendees asked what was most important to me – Osler’s Mission, Vision or Values.

Choosing which one resonates more than another is like choosing a favourite child – it’s impossible! But it did get me thinking about what each of these core statements means to me.

Mission: Innovative health care delivered with compassion

Osler’s Mission is a constant reminder that while health care is fluid and dynamic, compassionate patient care remains at the heart of everything we do. A key element of our Strategic Plan is to ensure that patients receive the right care, in the right place, from the right provider and, that care is delivered with compassion and empathy. We need to think beyond the traditional models of health care delivery toward innovation, which will play a critical role in changing health care for the better.

We’ve already begun to bring innovation into our programs and services. Our successful Telehomecare Program is helping patients with COPD and Heart Failure take charge of their health using technology while our hybrid endovascular surgery is providing world-class care closer to home. Along with these technological advances, we’re delivering compassionate care through initiatives like our palliative outpatient clinics that support patients as they manage their symptoms and we’re helping new comers to Canada gain access to and an understanding of health care services with settlement counsellors at each site.

And through innovative administrative partnerships with the Central West Community Care Access Centre (CCAC) and Headwaters Health Care Centre (Headwaters), we’ve taken a collaborative approach to planning to better support the delivery of quality, timely health care services across the regional health care system.

Vision: Patient-inspired health care without boundaries

These six words influence everything we do at Osler. Our Vision puts the patient experience front and centre of every care episode and I’m so pleased to see Osler staff, physicians and volunteers take this to heart every day.

As we continue to move toward a system where we see fewer unplanned hospital visits and more scheduled care, our partnerships with the Central West CCAC and Headwaters – as well as health care providers in the community – will become even more important. More seamless access to scheduled health care services throughout the region will help make sure patients receive the right care, in the right place, from the right provider.

Earlier this year, I wrote about the experience of an orthopaedic patient who attended her daughter’s Caribbean wedding by Skype from her hospital bed at Etobicoke General. The teams involved in orchestrating this experience took our promise of “going beyond” to a whole new level in a compassionate and meaningful way for this patient and her family.

Our Global Health team visited India earlier this year to see how we could share knowledge

Our Vision also means looking outside our local health care system. We’ve already begun to seek out new opportunities through our Global Health Program, which is exploring ways we can improve health care abroad as well as in our local community. Our Research Program will also help us to innovate as we uncover new patient-centred models of care that we can establish at Osler.

Values: Respect, Excellence, Accountability, Diversity, Innovation

Osler’s Values are woven into the fabric of our organization and I see the affect they have every single day. Our commitment to providing excellent patient care, respecting the dignity of everyone who touches our organization and being accountable to ourselves, our patients and our community create a positive environment that allows us to thrive. And by embracing diversity, we are able to bring new perspectives to the delivery of health care that help to drive innovation at all levels.

I believe that the combined strength of our Mission, Vision and Values – and the way that they are lived by everyone at Osler – is critical to our success now and in the future. It makes me proud to be part of such an amazing organization

Celebrating a Year of Innovation and Partnership

Do you remember what you were doing this time last year? At Osler, we were embarking on a journey with the Central West Community Care Access Centre (CCAC) and Headwaters Health Care Centre (Headwaters) that would change the way health care is delivered in our region.

Together, we announced an innovative cross-sector partnership that joined our non-clinical (administrative or ‘back-office’) functions to improve our collective ability to meet the health care needs of our communities. So far, we’ve worked hard to build solid foundations that will impact the way health care is delivered in our region.

Here’s a snapshot of what we’ve done this year:

Planning for the Future, Together

For the first time, we joined forces to develop our Annual Business Plans (ABP) and Quality Improvement Plans (QIP). By aligning our goals and monitoring them with a set of common metrics this will enable us to collectively improve health care quality and safety while having a positive, far-reaching impact on the patient experience across the Central West region.

We also worked together to showcase our individual and collective achievements from the past year in our Annual Reports in a fresh, dynamic way.

Leading the Way Forward

The old adage “two heads are better than one” certainly applies to the partnership. But for us, five heads are better than two. By creating a Joint Non-Clinical Executive Team, we pooled the collective resources and experience of all three organizations. This innovative approach to leadership has energized our senior teams and has created an environment that fosters collaboration and cooperation.

Weathering the Seasonal Surge

There’s nothing that tests the strength of a relationship better than a challenge. We put our partnership to the test as we collectively planned for and responded to a large patient surge during an exceptionally busy holiday season that was complicated by an early spike in flu activity. In a two week period, Osler saw a more than 8,800 patients visit our emergency departments (ED), admitted more than 1,000 patients for acute care and confirmed 350 flu cases.

Needless to say, this was a challenge but by working together we were able to effectively manage the flow of patients by providing excellent care in our hospitals as well as in the community.

Over the past year we saw first hand how working together can yield incredible results and spark new ideas about how we can improve the patient experience. We will share more achievements as our relationship matures over the months and years ahead. It is an exciting time for health care in the Central West region and I’m confident that the best is yet to come!

How Osler is working with the LHIN

There are many acronyms in health care. While medical dramas on TV have made many of these terms common place – like MRI (magnetic resonance imaging) and ED (emergency department) – there are some that are a bit more unfamiliar.

One of the terms we often use around Osler is LHIN, which stands for Local Health Integration Network. It’s a long name, but what does it mean?

The LHIN system is unique to Ontario and was created so health care spending decisions could be made by local people and money could be distributed in a way that better reflects local needs of regions across the province.

Across Ontario, there are 14 LHINs that bring health care decision-making to the regional level. Everything from the planning, coordinating, integrating and funding of local health care services is managed by individual LHINs across the province. Each LHIN is overseen by a provincially-appointed Board of Directors to ensure that they remain accountable.

Osler is located in the Central West LHIN and we work closely with the LHIN to deliver programs and services that make a difference in the lives of patients. The LHIN also works closely with health care providers in the community. This means that if you’ve received care at Osler, moved a loved one into a long-term care facility, accessed community support services or visited a community health centre – you have touched part of the LHIN.

Here are just a few examples of how Osler and the LHIN are working together to meet the needs of patients:

  • Patients with COPD and Heart Failure are now able to manage their health from home through Telehomecare
  • Diversity is in our DNA and Osler is part of the LHIN’s Diversity and Equity Core Action Group to help ensure all patients receive fair and equitable access to health care
  • We’re calling for better integrated care across the community through Telephone Town Hall meetings with our regional partners
  • Through the connectingGTA Program, Osler clinicians can access the health information they need to make care decisions using a secure regional electronic health record system

This is just the tip of the iceberg. As the health care needs of the communities we serve evolve, we will continue to work with our partners at the LHIN to improve access to services and find ways for health service providers to improve the quality of care.

First Impressions: What We Learned in India

This week’s guest blog is from Dr. Naveed Mohammad, VP Medical Affairs and Co-Lead of Osler’s Global Health Program

Earlier this year, I was fortunate to be part of a five-member clinical team that travelled to Punjab, India as part of Osler’s Global Health Program. During the 12 days we were on the ground, we were able to see how health care is delivered first hand.

The health care system in India is one of contrasts, where state-of-the-art, for-profit hospitals exist alongside charitable hospitals and access to care is largely based on what patients can afford. Amid this disparity we couldn’t deny the obvious common thread: regardless of where treatment was provided – be it in a high-tech hospital at the centre of a bustling city or a small clinic in a rural village – the patient is always at the heart of their care.

Families are part of the care team and from admission to discharge, they are always present to support the comfort needs of patients. Patient rooms are often equipped with a bed for the patient and a cot for a family member.  At Osler, we are already exploring ways we can enhance the patient experience through family presence initiatives.

Patient care is a family affair – Families are part of the care team and from admission to discharge, they are always present to support the comfort needs of patients. Patient rooms are often equipped with a bed for the patient and a cot for a family member. At Osler, we are already exploring ways we can enhance the patient experience through family presence initiatives.

Improving the patient experience - It’s natural for patients to have a lot of questions and concerns when navigating the health care system. All of the hospitals we visited in India had help desks to assist patients as they navigate the facility. At one hospital, once a patient sees a specialist, they had a patient counsellor who could provide further information about their care and answer follow-up questions.  We were inspired by this approach to care and came away with new ideas for how we can implement similar programs in some of our busiest departments. Osler is already setting the stage to launch our own patient concierge program in the ED.

Improving the patient experience – It’s natural for patients to have a lot of questions and concerns when navigating the health care system. All of the hospitals we visited in India had help desks to assist patients as they navigate the facility. At one hospital, once a patient sees a specialist, they had a patient counsellor who could provide further information about their care and answer follow-up questions. We were inspired by this approach to care and came away with new ideas for how we can implement similar programs in some of our busiest departments. Osler is already setting the stage to launch our own patient concierge program in the ED.

Revolving door approach to outpatient care -  Where do you go when you need a referral to a specialist? In Canada, our health care journey begins with our family physician. The weak primary care system in India has resulted in a stronger outpatient department (OPD) model, which also reduces the demand on their emergency department services.  Many of these interactions happen on an outpatient basis. Facilities are designed so patients can receive same-day care from a specialist and consult with multiple specialists providers under the same roof on the same day. This speedy approach to care virtually eliminates wait times that are so common in Canada.

Revolving door approach to outpatient care – Where do you go when you need a referral to a specialist? In Canada, our health care journey begins with our family physician. The weak primary care system in India has resulted in a stronger outpatient department (OPD) model, which also reduces the demand on their emergency department services. Many of these interactions happen on an outpatient basis. Facilities are designed so patients can receive same-day care from a specialist and consult with multiple specialists providers under the same roof on the same day. This speedy approach to care virtually eliminates wait times that are so common in Canada.

Mission accomplished

We travelled to India in search of partnership opportunities, and we found them. After a careful review Osler has chosen to work with two hospitals in the Ludhiana district where we will focus on service delivery, training/education and research, as well as a multi-national hospital chain on research.

  • Shaheed Kartar Singh Sarabha Ayurvedic Medical College & Hospital is a charitable hospital that serves a rural population while acting as a teaching centre for nursing students from 25 neighbouring villages. Partnering with this organization will enable us to assist with the development of health care infrastructure in this community through screening, education and outreach camps and sharing our best practices.
  • Dayanand Medical College & Hospital is a recognized health care leader in Punjab and tertiary care teaching hospital. Partnering with this organization will provide us with a unique opportunity to potentially support training in emergency medicine, critical care and psychiatry and to research the epidemiology of chronic disease in Punjab and within our local Central West region. There is also potential to provide continuity of care and share medical records for Osler patients travelling to this part of India.
  • Apollo Hospitals is an internationally accredited organization with over 50 hospitals across India. Partnering with this organization will provide us an opportunity to conduct research to understand various aspects of health and wellness, and disease progression and treatment for individuals of South Asian descent. There is also an opportunity to provide continuity of care and share medical records for Osler patients travelling to India.

Right now, we’re working to finalize Memorandums of Understanding with each hospital to define the specific initiatives Osler will support. A funding structure is also being developed with Osler Foundation to engage our community. Once these pieces are in place, the team will host a follow-up information session in the fall to provide details of our first official mission slated for early 2016 and how staff can apply.

These are exciting times at Osler and I look forward to the next phase of our Global Health Program!

Taking health global: Osler is headed to India

This week’s guest blog is from Dr. Naveed Mohammad, VP Medical Affairs and Co-Lead of Osler’s Global Health Program

India is a fascinating country. From its rich history and vibrant cultural traditions to its colourful festivals and culinary delights, it’s easy to become captivated. Living and working in the Greater Toronto Area means that we are very fortunate to be able to experience so much of what this culture has to offer without needing to travel too far.

Osler serves one of the fastest growing and most diverse communities in Ontario. According to data collected during the 2011 Census, more than 62 per cent of recent immigrants to Brampton and 42 per cent of immigrants to north Etobicoke are from India. This incredible statistic signals that the dynamics of providing health care need to change to meet unique needs of this growing patient population in the best way possible.

Given the extensive Punjabi community within our region, we decided that this area was the logical starting point for our Global Health Program. After months of extensive planning, a five-member clinical team from Osler will be travelling half way around the world to the Punjab region of India to explore ways we can contribute to the homelands of our local citizens and gather valuable insights on innovative practices that can be used to better meet the needs of our community.

When I was asked to be the clinical lead for the mission to India, I jumped at the opportunity to approach global health in a new way. Osler identified six clinical areas where there is the greatest potential for impact and the tour team was chosen based on these needs. The team includes:

  • David Koczerginski, Corporate Chief of Psychiatry and Medical Director of Mental Health and Addictions
  • Davinder Wadehra, Medical Director of Nephrology (representing chronic disease area)
  • Kelly Falzon, Director of Women’s, Children’s and Seniors Program
  • Gurpreet Rosales, Project Manager and Global Health Program Lead

I’m thrilled to be part of the team headed to India and right now, we are preparing to meet with hospital leaders and non-governmental organizations (NGOs) in the cities of Chandigarh, Ludhiana, Amritsar and surrounding areas to learn more about health care in this region. We will also be visiting hospital-affiliated satellite clinics in rural areas where the team will see first-hand how health care services are delivered, which I imagine will be an extremely rewarding aspect of the trip.

An international mission like this doesn’t happen overnight. We have been carefully planning this tour for the past 18 months under the leadership of Susan deRyk and Gia D’Souza from Osler’s strategy team with strong support of the Global Health Steering Committee, an Advisory Group made up of staff and community members whose feedback has helped shape this experience, and Osler Foundation.

As we journey across Punjab, we will be sharing our experiences along the way. Follow @OslerHealth on Twitter and like our Facebook page for updates from the field. I personally can’t wait to share details about our experience and the exciting partnership opportunities that lie ahead!