Abstract
Background: Access and flow remains an ongoing challenge for publicly-funded health systems. Community agencies are expected to provide timely access to care for individuals with fluctuating health conditions, including complex behaviours. Head Injury Rehabilitation Ontario (HIRO) manages complex behaviours in community, supporting hospital discharge and preventing inappropriate hospital admissions. By focusing on improving access, objectivity, and collaboration, HIRO has successfully navigated tensions, improving system flow and enhancing client outcomes. The model below is transferable to other community providers defining their role in access and flow, and examples of outputs since HIRO's implementation are offered as evidence of its success.
Audience: This model is valuable to community care providers who are seeking to define their unique value within care pathways, and would benefit from tools to objectively define their value to facilitate more productive, results-oriented discussions when navigating clients to/from acute and community care.
Approach: The model encompasses 3 primary themes as listed below. Examples of tasks that can be conducted internally to facilitate that theme are included:
1) REDUCE BARRIERS TO ACCESS AND IMPROVE SYSTEM FLOW. Community agencies may have unintentional barriers to access and flow, due to inheriting criteria without critical appraisal:
-Critically assess the 'why' behind each individual admission and discharge criterion for your service(s)
-Confirm your admissions procedures align with population health initiatives, and have ethical and equitable waitlist management principles
2) DEFINE "COMMUNITY-READY". The Community Sector are experts at defining what they are able to support in the community; therefore, they must work with system partners in other sectors to understand what 'community-ready' means for them:
-Ensure you align with the latest funder agreements, regulations, and legislation
-Use common language (e.g. What does 'independent' mean? 'Stable'? 'Risk'?)
3) REDUCE SERVICE DUPLICATION AND ENHANCE INTEGRATION. Ensure your services fill a gap, and do not duplicate existing services:
-Complete an environmental scan and needs assessment
Results: By executing the model, HIRO has had the following outputs:
Task 1: In 24 months, HIRO increased admissions by 30%; HIRO also removed a client from hospital successfully by challenging our own admissions criteria, supporting system flow.
Task 2: HIRO defined 'community-ready' with a hospital partner, and successfully admitted a long-term inpatient client from hospital by clarifying miscommunications.
Task 3: By partnering with Primary Care, HIRO reduced hospital re-admissions by 82% in the last 5 years. HIRO also worked with long-term care facilities to better understand their barriers to admitting clients with behaviours, and HIRO was able to overturn a denial by supporting the skill development of a patient and the staff of the long-term care facility.
Implications: A model such as this requires a significant amount of humility, respectful curiosity, and critical appraisal. It is necessary to consult with your stakeholders to evolve your services, and to show a collaborative commitment to the same goals of patient access and flow using an ethically-sound, safety-focused, and equitable model.