Partnering for patients to make transitions seamless

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A patient’s transition from hospital to home is a critical time in their health care journey. While hospitals and community care services are there to help, the systems in place can be difficult for patients and caregivers to navigate.

The Mississauga Halton Community Care Access Centre (CCAC) and Trillium Health Partners are working together to find a more patient-centred way to transition patients from hospital to home.

Coined the Seamless Transitions initiative, this work is guided by a Joint Steering Committee comprised of both Trillium Health Partners and Mississauga Halton CCAC leadership, with implementation led by a design team of frontline staff, CCAC representatives, physicians, patients and caregivers, all of whom are guided by a shared set of principles.

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“What we are doing with Seamless Transitions is game-changing for patients and families,” says Caroline Brereton, CEO of the Mississauga Halton CCAC. “By working together in a full and equal partnership we can re-imagine and re-design the way we care for patients in the region, delivering consistent, high quality care from hospital to home.”

“We didn’t start with a solution; we started with a problem that was common to the hospital and the CCAC and worked together to find the best solution for the care providers, patients and their families,” says Michelle Samm, Project Lead of the Design Team. “We recognized that we needed to build something different that would also help us better organize ourselves around the needs of our patients – something from the ground up, not what hasn’t worked in the past.”

Over a six week period, the multidisciplinary team has been collecting feedback through a series of brainstorming sessions, where staff from the hospital and Mississauga Halton CCAC, patients, caregivers and community providers share ideas about what a more patient-centred approach could look like. Engaging all those involved in the transition from hospital to home was integral in designing the new model.

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The project is then moving into a testing phase of this new, more patient-centred approach. Collaboration between the hospital and the CCAC will continue through the evaluation and subsequent implementation of Seamless Transitions.

Why is this work important?

Mississauga, West Toronto and the neighbouring communities are growing at a rapid rate, with a large aging population with increasingly complex needs. This is one of the fastest-growing communities in Canada, with an expected growth of 63 per cent in the next 20 years – amounting to 1.8 million people – larger than most urban centres in Canada today.

As one of the largest community-based and acute care facilities in Canada, Trillium Health Partners serves more than 1.5 million patients each year. On any given day, Trillium Health Partners is over capacity with 70 to 100 patients waiting for a bed. “We know that when patients transition seamlessly from hospital to home, average lengths of stay decline, readmission rates are lower, patient experience improves, and desperately needed beds free up for patients who are waiting in hallways,” says Dr. Dante Morra, Chief of Staff at Trillium Health Partners.

The Seamless Transitions initiative is one part of an ongoing partnership between the Mississauga Halton CCAC and Trillium Health Partners. The two organizations will continue to work closely on future health care initiatives and hope other health care providers will follow their lead. By improving communication between health care providers and focusing on a patient-centred model of care, the entire Ontario health care system will benefit.