Abstract
Background: Prolonged hospitalization can be associated with poor health outcomes and functional decline, resulting in longer hospital stays and failure to return home.
Approach: Nova Scotia Health (Provincial Health Authority) and Shannex (private sector, family-owned company) have partnered to co-design a new model of transitional health in Nova Scotia, Canada. The model offers an alternative setting for Nova Scotia Health patients who do not require acute care but require additional time, support, and resources to return home.
Staffing ratios, policies, processes, building design, equipment, resources, care plans and shared InterRAI assessments are intentionally co-designed to meet patient goals of care, all of which have been informed by feedback from patient and family advisors. A joint interdisciplinary team partners with the patient and family to develop and achieve discharge goals, providing case management and guidance in the home for up to 16 weeks post discharge.
Newly developed pathways outline the management of patient flow to and from the Transitional Health facility. The pathways include the management of flow back to hospital for patients who
require urgent or emergency care. Pathways for admissions directly from community and emergency departments prevent hospital admissions.
Twenty-four transitional health beds have opened since July 10, 2024. An additional 68 beds are planned to open by March 2025 and another 110 beds in 2026. In 2026, the model will include co-designed programs to support bariatric health and behavioural health care.
Results: Between July 10 and November 4, 33 patients have received transitional health care. Preliminary results show that some patients have experienced a change in discharge disposition, requiring a lower level of care than anticipated while hospitalized. Patients have experienced an improvement in physical function, social functioning, and mood. This alternative care setting has saved close to 2000 conservable acute care bed days over 14 weeks. Further, a quieter setting with private rooms and opportunities for social engagement has shown beneficial in conducting physical and cognitive assessments, giving more accurate results for planning discharge home. Evaluation and monitoring will be overseen by an established joint NSH/Shannex Quality and Patient Family Advisory Committee utilizing an evaluation framework.
Implications: Transitional health is an alternative to acute care hospitalization. Avoiding unnecessary and prolonged hospitalizations prevents functional, social, and cognitive decline which means patients can go home sooner and live at home longer. Continuity of case management and shared InterRAI assessments post discharge ensures greater chance for success, preventing readmission to acute care, overall, positively impacting healthcare quality and access for all Nova Scotians.