When people are discharged from the hospital those involved should know what the follow-up care plan is, and with whom and when care will happen. This applies to individuals, families and providers. The current system is not efficient, leading to readmissions and poor care after leaving the hospital.
The Coordinated Discharge Working Group worked on coordinated care transitions to reduce emergency department visits and readmissions to hospitals and improve people’s recovery after being in the hospital.
Current Challenges
- Many people do not have the support they need for a smooth transition or recovery after being discharged from one of the three hospitals - Kingston Health. Sciences Centre, Lennox & Addington Community General Hospital and Providence Care Hospital.
- Communication among the hospitals and community providers is not always coordinated or consistent.
- Without proper follow up after leaving the hospital, people are at risk of readmission, emergency visits and poor recovery.
What we are working towards
We are working at improving the discharge process for people leaving any of the three partner hospitals and standardizing the patient discharge summaries. Another area of our work is connecting people at risk of admission to a hospital to appropriate community supports
We will measure the impact of improved coordination of hospital discharge and continuity of care, such as:
- reductions in readmissions to hospital
- reductions in urgent care/emergency room visits
- improvements in health and wellness
- improvements in experiences for clients, families and providers
This working group is currently on pause.
This is a temporary measure. We look forward to resuming our activities in the near future. This page will be updated on any further developments as we resume our work.
Coordinated Discharge Projects
Hospital Discharge Process Review
The process for coordinating care after a person is discharged from the hospital was reviewed in early 2022 by a process improvement specialist, in collaboration with the partners involved.
Recommendations were made relating to developing a care navigator role and standardizing the discharge process.
Health Home Care Navigator
A Care Navigator role was created in the Frontenac Doctors. The Victorian Order of Nurses (VON) offered a team member in-kind for the pilot, which started on September 6, 2022 and ended in February 2023.
Throughout the pilot, the Health Home Care Navigator was able to support 71 patients with their transitions from a hospital to home and to engage 54 frail, elderly patients to confirm they were managing well in their homes and help coordinate services to maintain independence.
Many benefits and lessons learned were recorded during the course of the pilot and will be used to inform any future implementations of a Health Home Care Navigator role.
Standardizing Patient Discharge
A Patient-oriented Discharge Summary template was co-designed by people and health-care providers.
The template:
- is a set of instructions to help people and families know how to manage at home after leaving the hospital.
- is helping people and their caregivers better manage their care at home.
- is being considered by the three partner hospitals and by the Lumeo project team, as they build the regional Health Information System.
Who's involved?
Community members, primary and community care providers, municipalities, hospitals and specialists from across the region are working together.
Community members may include people with lived experience, family, caregivers, Indigenous and Francophone representatives, 2SLGBTQ+ and others.