Returning home after cardiac surgery can be daunting for patients and families, who often have questions once they leave the hospital. They wonder whether symptoms are a normal part of recovery or whether they may have misinterpreted the doctors’ instructions.  Without a guaranteed community support system after discharge, many patients end up coming back to the emergency department (ED) for answers and some end up being readmitted to hospital. 

“It was scary leaving the hospital,” says Rhonda Morrissey, 55, who recently had quadruple bypass surgery at Trillium Health Partners’ Mississauga Hospital site. “I’ve never had anything seriously wrong with me before and didn’t know what to expect.”

The cardiac surgery team at Trillium Health Partners (THP) had long recognized the need and expressed the desire to maintain a supportive connection with their patients once discharged from the hospital. The opportunity to realize this goal came when THP was chosen by the Ontario Ministry of Health and Long-Term Care as one of six provincial pilot projects that will help patients transition from hospital to home more seamlessly using a new approach called bundled care.

The bundled care model aims to coordinate services around the needs of the patient as they move through the health care system and eventually back to their homes.

The foundation for THP’s successful bundled care proposal is a ground-breaking partnership with Saint Elizabeth Health Care, a national organization that provides a full range of integrated care services in the home and in the community. The partnership simplifies follow-up care for patients by bringing the hospital and home care teams together to jointly develop the post-discharge care plan for the patient. Hospital and home care nurses then work together to ensure patients heal and recover well after cardiac surgery, avoiding trips to the ED or potential readmission to hospital.

“Creating a formal partnership has allowed us to enhance communication and work closely together as one team,” says Rheta Fanizza, Chief Business Officer and Senior Vice President of Innovation at Saint Elizabeth.

As a regional centre for cardiac care with the second-highest volume of cardiac surgery patients in the province, THP knew the new approach, called Putting Patients at the Heart (PPATH), would greatly improve the patient experience.

“When we were designing PPATH, we asked our patients what they needed to feel supported and confident to recover at home after cardiac surgery,” says Patti Cochrane, Senior Vice President, Clinical Strategy and Chief Innovation Officer, THP. “They told us they want to be actively involved in planning their care, to know who to call if they are worried about symptoms, such as shortness of breath or chest pain. Even though each patient receives education about what to expect before, during and after their surgery, they told us it can be difficult to process in the moment and they begin to second-guess themselves when they return home. Patients and their caregivers can begin to feel overwhelmed, and without proper home supports in place, the patients often end up back at our hospital, which is not where they would ideally like to be.”

Using extensive patient and provider feedback, the PPATH strategy was built to incorporate several key tools into the patient pathway, many of which focus on continuity of care and connectivity between patients and their health care teams so that everyone within the circle of care understands what to expect at each point of the journey.

An Integrated Care Coordinator (ICC) role supports each patient throughout their entire journey, from the moment they are listed for surgery, through the procedure, hospital recovery and transition back to the community. The ICC also coordinates any required post-discharge home supports in collaboration with Saint Elizabeth, matching the needs of each individual patient with the services provided by the Saint Elizabeth team.

“PPATH has been a collaborative effort between many teams at THP and Saint Elizabeth,” says Dr. Charles Cutrara, Chief of Cardiac Surgery at THP. “From the IT support to the clinical teams, decision support and project management, the interdisciplinary team that brought this strategy to life truly demonstrates the meaning of partnership and excellence.”

Technology developed with Information Services at THP is another key to making the partnership work for both patients and providers. The teams at both Saint Elizabeth and THP have access to a single electronic record for each patient using a specially-designed dashboard where they can view real time information and track patients across the continuum of care. Saint Elizabeth nurses can also consult with THP’s cardiac team right from the patient’s home using secure phones and tablets.

As a direct response to patient feedback, PPATH established a 24-hour phone line monitored by care coordinators that allows patients to address their questions and concerns without visiting the Emergency Department. If necessary, the care coordinator can then mobilize a Saint Elizabeth nurse to the patient’s home for an assessment and to recommend next steps.

When Rhonda developed a high fever a week after surgery, she called the 24-hour line and the coordinator immediately arranged for a Saint Elizabeth nurse to visit Rhonda’s home. The nurse sent a photo of Rhonda’s incision to THP, where a surgeon confirmed a potentially significant wound complication and faxed a prescription to Rhonda’s pharmacy, allowing treatment to begin within just a few hours. Already feeling better, Rhonda visited the cardiac ambulatory clinic the next day to see the surgeon for additional follow-up.

“I called and in less than 5 minutes they called me back. I found it extremely helpful,” says Rhonda about the dedicated phone line. “After I saw the surgeon again at the clinic they called again several times to check up on me. It was great knowing all I had to do was pick up the phone — way better than going to Emergency.”

PPATH was officially launched in February, 2016 and early data shows a reduced length of stay for patients of two days, a significant reduction in post-discharge ED visits, as well as positive patient and care provider feedback. Within the first three months, 155 cardiac surgery patients were registered with PPATH.

Additional tools such as new patient education methods and tele-monitoring will be rolled out over the coming months as PPATH scales up and builds capacity.

“This is a very exciting and positive experience,” says Elena Holt, Program Director, Cardiac Health for THP. “We’ve been looking for a solution to this problem for many years and as we continue to measure the success of PPATH, we hope to be able to expand the new model, not only within cardiac surgery but throughout other hospital programs, the community and beyond. The future is very bright for this type of care.”