JUDGE’S CHOICE AWARD
By: Head Home, Speak Up
In the current health care environment, where there is an ever growing demand for services, the government is under pressure to deliver more with constrained financial and human resources. One cost reduction solution is discharging hospitalized patients to their homes with continued care provided by homecare services. Homecare is better for both patients and the healthcare system. Patients benefit from improved quality of life and can continue living independently when treated at home. The healthcare system benefits from improved cost-effectiveness relative to care in an institutional setting like a hospital or long term care facility.
The discharge to homecare, however, is fraught with danger. Upon decision to discharge, the interdisciplinary hospital team writes a discharge summary describing the care received. This must detail important information such as medications and instructions for follow up care. Post-discharge follow up, a crucial component of the patient’s continued care, is handed off to the patient’s family physician. The patient must also be connected to the Community Care Provider (CCP) for follow up nursing, rehabilitation, or other homecare services. Currently, this system leaves the patient extremely vulnerable, as no single party is responsible for all aspects of the patient’s care. Lapses may occur when, for example, miscommunication occurs between providers or follow up for necessary care in the community is delayed. These issues are compounded by variability in the discharge process.
There is no standardized documentation process for discharge across hospitals, increasing the likelihood of inconsistencies in communication and quality of handoff. Also, there are significant variations between hospitals in the time to complete discharges; for example, the average time required to complete 90% of discharges varied from 10 to 139 days across Ontario Hospitals1. Any combination of these events could result in the patient falling through the cracks and not receiving the care he or she needs.
The Solution: Community Care Online Portal
To support continuity of care and smooth the transition between hospital-based and community care services, the proposed solution would provide all stakeholders (hospital providers, family physician, CCP, and patient) with real-time, up-to-date information on the progress of the discharge. Our solution involves building a secure, online community care portal. Each patient discharged from the hospital would be assigned a unique identification number tied to an online profile at discharge. All members of the circle of care and the patient would be able to login using the ID to view the profile. Crucially, each member would also be able to voluntarily provide feedback about the progress, successes, and failures of the discharge. The portal would contain the following:
Patient Profile Information: Basic biographical information detailing the patient, the date of discharge, etc.
Provider Contact Information: Hospital interdisciplinary team (Physician, Social Worker, Physiotherapy, Occupational Therapy, etc.), CCP, and Primary Care Physician. The patient can see who was involved in their care and how they can be reached for follow up.
Status Updates: Updated to reflect the completion of discharge orders. Patients would be able to report whether they had received the services listed. If, for example, a patient was unsuccessful in receiving the services or medications outlined at discharge, an automated update could be sent to the CCP case manager, the family physician, or the referring hospital team advising them to follow up. For example, a patient might discover after discharge that a required medication is very expensive when ordered through a private pharmacy, resulting in a return to the emergency department to have the medication administered. An update could be sent to the CCP reiterating the need for a nurse to visit to provide the medication with provincial subsidization, or to the family physician encouraging follow up to change the medication.
Feedback Survey: All members participating in each discharge could provide voluntary feedback. Patients would feel empowered to speak out about the successes and failures they experienced while under care. Because the portal is voluntary, providers would not be required to fill out additional paperwork unnecessarily. They would be able to speak out, however, when a serious lapse has occurred. Individualized surveys could be prepared for common discharge types (e.g. rehabilitation after hip surgery), with quick Likert scale (strongly disagree to strongly agree) questions tailored to specific targets (e.g. satisfaction with ability to complete activities of daily living). Comments could also be collected to allow more detailed feedback, meaning that innovative solutions could be crowd‐sourced at the level of individual patients and providers. Data could be anonymized to allow for the production of aggregate performance statistics. This could be used to track performance across different geographic locations, patient populations, or diagnoses. This sort of feedback would help close the loop of discharge, allowing the healthcare system to identify strong programs to emulate and weak ones to improve.
The implementation of the portal would involve the development of a secure, online web portal for the stakeholders to use. This portal would be designed to adhere to the existing privacy protection and security legislation mandated by each province. The growing familiarity of both patients and providers with the internet and social media could make such a portal a natural part of the health care experience.
Is the healthcare system is pressured to work under fiscal constraints, there will be an increasing shift towards homecare and community services to help contain healthcare costs. The need for homecare services is estimated to be 10% of all hospital discharges, or 200,000 patients per year in Ontario alone. The benefits of this solution are three-fold: improved access to care, improved patient experience, and improved efficiency in delivering care. By enabling patients to take a proactive approach to their healthcare, the portal also acts as a double-check mechanism so all stakeholders can identify when follow up has been unsuccessful. Performance differences between different regional providers could be identified so that lessons could be learned and changes made when necessary. Public reporting of anonymous aggregate statistics could also be considered to improve accountability. Finally, real-time feedback would allow for truly continuous improvement, with instant surveys helping to identify key factors to study more formally.
Community Care Home: The portal could eventually grow to be the center of the patient’s homecare experience. Many patients feel unable to discuss problems with homecare as they are concerned that negative feedback could result in their care being compromised. Anonymous aggregate statistics could help to identify systemic problems with businesses contracted by the CCP. Patients could also be encouraged to correspond regularly through their portal with their CCP. Currently CCPs spend a significant number of hours commuting between patients. It might be possible to replace some of these visits with online updates by patients or their family members, maximizing the use of scarce CCP resources. Patients could also use the portal as a record of their care; for example, they could look up contact information of a previous provider.
Post-Discharge Orders and Health Information: As electronic health records are rolled out and appropriate privacy safeguards are put in place, the portal could be expanded to link to additional health information such as the full discharge summary, changes in medication made by providers, and information on follow up appointments.