Abstract
Background: The co-creation of integrated care delivery models and digital health tools with clinicians, patients, and their families is needed to address gaps in trajectories and transitions of rehabilitation care. Clients often refer to transitions as the in-betweens where they feel alone to rebuild your [their] day-to-day activities, to restore your [their] routine, to maintain your [their] physical activity level. Integrated practice units (IPU) can help during transitions by improving communication, coordination, and continuity of care. Digital health tools and evaluation protocols support IPUs by providing opportunities to increase efficiencies in care, application of stroke best practices, and activating patient and family involvement while optimizing costs.
Approach: The CCOMTL health region in 209 created the Neurosciences IPU to ensure a smoother transition for clients from inpatient care to outpatient services and improve links with community partners and home-care services. The IPU includes a client and caregiver focus, integrated comprehensive care paths, with smooth transfer across a fixed or virtual team of providers, ongoing performance management and improvement cycles with input from patient experience measures and outcomes, and value-based healthcare (VBHC) evaluations. In collaboration with BRILLIANT, an academic and clinical partnership, an integrated knowledge translation and qualitative methodology was used to identify needs and gaps in rehabilitation trajectories and co-create digital health tools. Forty-five clinicians and 25 patients/caregivers across the CCOMTL and three other health regions participated in focus groups or interviews for the co-creation of digital health solutions. Two digital tools were developed that will form part of a trajectory platform: the electronic Mayo-Portland Assessment Inventory (e-MPAI), and the clinical information system for the Early Supported Discharge (ESD) program.
Results: Data from the VBHC business intelligence system of the CCOMTL showed that, between 209 and 2022, on average the length of stay in acute care decreased by 2 days and the time to initiate in-patient rehabilitation decreased from 20 days to 4.4 days. The cost per episode decreased on average by $000. The needs and gaps across trajectories of care that digital health tools can help address were classified under five themes: ) Enabling continuity of care (e.g. standardized assessments), 2) System design (e.g. information services), 3) Community service accessibility, 4) Transportation services, 5) Individuals uncertainty during transitions. The development of the eMPAI occurred over four meetings within each health setting and two inter-site meetings. The main gaps addressed by the e-MPAI were to provide a standardized metric to the clinical team to evaluate patient activity limitations and participation restrictions when they transition from in-patient to community care, and a dashboard to support decision-making at the individual patient level and program level. The eMPAI has been used for 5 clients, with scores of 45% being shared across transitions of care between health regions.The co-creation of the ESD clinical information system occurred over year with the coordinator, clinicians, and a patient partner. The system includes the following modules: Standardized measures; Communication and information exchange; Shared intervention plan and goals; Client self-management support; and Quality improvement dashboard. Implementation of the platform is starting and indicators of adoption, impact on efficiencies of care, clinician best practice and experience, and client outcomes and experience will be evaluated.Implications: The development of the Neuroscience IPU and the co-creation of digital health tools represents a path to improving stroke care by providing the right intervention to the right person at the right time, accounting for long-term functional potential and meaningful participation in the community. The IPU aims to improve VBHC by integrating digital health into workflows, including standardized assessments with decision support, to optimize the organization of care across the continuum and during transitions.