Transforming Transitions: A Co-designed Digital Shared Care Plan for Coordinated, Patient-Centered Care Integration

Background: Mackenzie Helps (MHelps) is a hospital to home program that has been developed in partnership between Mackenzie Health Hospital, Saint Elizabeth (SE) Health, CHATS-Community & Home Assistance to Seniors and LOFT Community Services. This program is designed to support patients as they transition from hospital care to home and community-based care and is offered over 16 or 26 weeks depending on the level of care needs of the client. A significant challenge for coordinating care across multiple providers in the community is the lack of visibility into the care provided for the patient .

Our care partners were documenting in their own electronic medical record that does not enable integration for data sharing between one another. Consequently, data sharing could only be achieved via paper/email, fax or verbal communications between care partners, which can easily lead to errors associated with transcription, missing or incomplete information, and/or misinterpretation of the information.

 

Approach: This presented us with key opportunities for growth in the program to help address the multiple fragmented care plans on various systems, reduce duplicitous and 'on-paper' communication, and provide better access to key health information to support care planning and decision making. Collaboratively, we developed a single standardized clinical documentation platform where all care partners contribute on one Shared Care Plan.

 

Results: Having a secure, shared electronic record has been a key enabler to streamlining care coordination, enhancing patient safety, and allowing us to evaluate data and outcomes at the patient level across multiple providers. It has also improved the provider experience in working with other organizations to coordinate care. This program has demonstrated success in reducing hospital readmissions, improving patient outcomes and has provided patients with the care they require to safely recover at home.

 

Implications: The success of this program from both the perspective of improving patient care and improving collaboration across multiple providers, demonstrates the importance of integrated care approaches that are digitally enabled. Having a unified data sharing process and visibility to standard documentation across organizations are key success factors in implementing an electronic shared care plan to enable integrated care in the healthcare system.