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Managing Transitions: A Seamless System that is Simple to Navigate
OACCAC Conference
June 20, 2013
Michelle Samm
Senior Project Manager
1 Integrated Hospital Transitions Project
Transitions of Care
A set of actions designed to ensure the
coordination and continuity of care
as patients transfer between different
locations or different levels of care in
the same location
Coleman, E.A. Berenson, R.A. Lost in Transition: Challenges and Opportunities
for Improving the Quality of Transitional Care Ann Intern Med 2004; 140:533-36
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Mississauga Halton LHIN
• History of successful implementation of
innovative strategies
• Increased focus on providing care in the
community
• Strong community sector
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Patients/Caregivers Experience
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....system-level transformation is required to meet the needs of MH LHIN
residents
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To achieve transformational change
through a single point of
accountability for hospital transitions
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Our Goal
System-Level Benefits
•Increase in client/patient/family satisfaction through seamless transitions and enhanced
engagement in their care
•Decrease in ED visits and readmission rates through enhanced transition planning and follow-up
care
•Reduction in LOS through timely discharges
•Decrease in ALC by promoting timely notifications
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Our Journey
Current State
Leading Practice
Principles &
Philosophy
Future State
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Phase 1
Current State Approach
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Interviews
&
Focus Groups
Document
Review
Data
Analysis
Current State Findings
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• Process is fragmented
• Inadequate timeliness and
quality of information
• Insufficient collaboration,
cooperation and communication
• Multiple assessments, duplication
and repetition
• Discharge process is confusing
System Level Opportunities for Improvement
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Leading Practice Approach
Successful models were identified from
leading jurisdictions, based on the
following criteria:
• Relevance
• Coordination
• Improvement
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Leading Organizations Examined
Massachusetts State Quality Improvement
Institute
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Leading Practice Findings
• A shared vision defining the ideal state for transitions
1. Shared Vision
• Common principles that capture values and priorities
2. Common Principles
• Defined roles and expectations for the “sending team,” “receiving team,” and the patient/family
3. Defined Accountabilities
4. Core Components
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• Core components (processes, activities, and tools) that comprise the transition model
Future State Approach
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Current
State
Leading
Practice
Integrated
Transition Model
1. Our Shared Vision
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Safe, effective, timely care during transitions between and within settings of care
2. Our Principles
Client/Patient
Centered
Safe
Equitable
Dynamic
Effective
Timely
Efficient
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3. Accountability
Integrated Leadership Team
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4. Core Components
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Assess
Plan
Empower
Support
Our Model
Pre Discharge Post Discharge
Assess for Needs
Plan for Transitions
Empower Client/Patient/Families
Support for Transition
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Continuum of Care
Se
am
less
, C
om
pre
he
nsi
ve
Ca
re
Assess
Standardized assessments that is supported by a
common tool and enables
patient stratification based on
post discharge needs
Empower
Early planning is enabled by collective access to
information and supported by
standardize tools
Plan
Clients/patients are
educated and empowered
through a comprehensive
array of tools and resources
Support
Continuity of care is extended
through smart feedback
loops linked to the
appropriate tools and
resources
IHTM
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Key Assumptions
• System level
• Design
• Operational
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Key Learnings
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Next Steps
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Initiative # 1
Initiative #2
Initiative #3
Initiative #4
Initiative #5
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