Abstract
Background: There is growing recognition of the importance and benefits of patient-and caregiver-centred care approaches for older adults and individuals with complex medical needs during points of care transitions. Effective care transitions can improve patient, caregiver, and provider experiences, and reduce avoidable emergency department visits and readmissions. Despite the widely recognized benefit of effective care transitions, health care programs have struggled with how best to design, implement, and sustain strategies to improve transitions of care for complex individuals. In 2019, St. Joseph’s Health Care London (Ontario, Canada), was awarded funds to improve the quality of care and patient and caregiver experience during transitions through the implementation of transition strategies. A number of interviews and focus groups were conducted to understand current experiences, and identify areas for improvement. Additionally, best practice transition strategies were adapted from Healthcare Excellence Canada. A working group was established with frontline and leadership representation, as well as two patient/caregiver representatives to oversee the work.
Co-Design Approach: Through multiple co-design sessions, the following tools and strategies were co-developed and/or modified for implementation: i) patient orientated discharge summary; ii) teach-back education processes; iii) post discharge follow-up phone calls; iv) welcoming caregivers as partners in care, and v) care resource binder. Many of these strategies were mid-implementation at the onset of the pandemic and lost momentum due to system pressures and shifting priorities. In Summer 2022, the working group re-assembled to re-ignite this work with a campaign to generate awareness and get frontline staff excited for the work to come. The team developed a campaign, Recipe for Success, which highlights a recipe card with a description of the ‘ingredients’ (transition strategies) needed for a successful transition. Virtual sessions, co-presented with patient/caregiver partners, were held to raise awareness and provide foundational knowledge on the tools and strategies. Over 100 participants attended the webinar sessions to learn more about the work. Tools were implemented into practice across the rehabilitation and geriatric inpatient programs. Follow up information has been collected to capture experiences and outcomes. Early findings indicate an improvement in care transition experiences.
Discussion and Next Steps: A number of key learnings have emerged from this work related to the development and implementation of transition strategies. Input from patients, caregivers and providers – from the beginning, clear communication, a strong workplan, and multiple training sessions were critical for the success of the initiative. The team is actively spreading this work to other units and programs across the organization.