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.
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: