A new program at Rouge Valley Health System (RVHS) in Ontario is providing comprehensive support to those coming out of hospital.

Care After The Care in Hospital, or CATCH, offers services to inpatient populations as they transition from inpatient to outpatient care in a community setting. While there are other discharge follow-up programs in the Greater Toronto Area, the level of personalized care offered in CATCH is unique in the province. (See sidebar)

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“There was a gap in terms of the support that our patients had when they go home,” says Amber Curry, manager, inpatient surgery, ambulatory care unit, pre-admit and fracture clinic at RVHS. “There wasn’t enough support to ensure that the patient continued to improve and could stay at home. This program fills in the time gap when patients first leave hospital and are at risk until they return home. With CATCH, we can identify whether there is a problem and address it more urgently, before there becomes a need for readmission.”

CATCH has three goals:

• Make sure patients have a safe transition back home;
• Follow up with any risk factors and/or reconditioning needs that patients may have; and
• Provide patients with support so that they can keep living safely in the community and don’t need to be readmitted to the hospital.

“The patients we serve in CATCH have more co-morbidities and more complex needs,” says Aaisha Savvas, manager, complex continuing care and outpatient rehab services at RVHS. “We want them to feel confident when they go home, knowing they can manage their care, and not end up back in hospital.”

RVHS patient Sharon Chambers, 65, recently completed her time at the CATCH program. Living with chronic obstructive pulmonary disease (COPD), Chambers found herself in hospital for a week last November after contracting a chest infection.

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On oxygen for several days and lying in a hospital bed, Chambers found that her ability to move, which was already compromised from the COPD, deteriorated rapidly. Because of the complex nature of her case, Chambers was referred to CATCH before her discharge. She went for several weeks, twice a week, to Rouge Valley Ajax and Pickering hospital campus. During the program, her occupational/physical therapy assistant Carol Hylton-Ehlers taught her various exercises to build up her legs, knees, and hips. Hylton-Ehlers never left her side while she was there. “It was nice to have someone there watching me. It gave me a sense of security; I knew there was someone there if I fell or something,” says Chambers. Kristin Bain, a registered practical nurse (RPN), also helped with Chambers’ reconditioning program and was on hand if Chambers had any questions.

Chambers continues: “I never thought I could do those exercises. They didn’t push me, just had me do as much as I could. But this helped me with my mobility and my breathing. Now, I understand what I can do, when to take a time-out, and when I am able to exercise. Without CATCH, I’d just be sitting at home doing nothing.” She does her exercises at home daily.

Initial statistics on the program show this type of patient success is typical: more than 400 patients have been seen in eight months. None of them have been readmitted to hospital. In comparing similar populations without this service, the 30, 60, and 90-day rates of readmission were 15.5 per cent, 20.6 per cent, and 25.26 per cent respectively. The comparison group consisted of Rouge Valley patients discharged from the same floors, with a similar age and length of stay in hospital.

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The program is getting recognition in the community. Last June, the CATCH program received the Our Choice Award at the Central East Regional Specialized Geriatric Services’ conference (RSGS) in Lindsay, Ontario. A committee representing seniors and caregivers from the Central East Region considered several programs, and chose CATCH as the one that most clearly demonstrated a commitment to improving the care experience for older adults. The program also recently received additional dollars to expand the service through the Central East Local Health Integration Network’s Assess and Restore Program funding.

Curry says they are seeing positive patient feedback about the program as well. “Patients are happy with CATCH. We provide patient questionnaires, and we get feedback that we should be referring more people to the program,” she says.

Chambers knows that CATCH helped her put her hospital stay behind her. “For me, it showed me I could be mobile. It built up my confidence.”

How CATCH works

• CATCH is offered by an interdisciplinary team of health professionals, including a general internist, physiotherapist, occupational/physical therapy assistant (OTA/PTA), and a registered practical nurse (RPN).
• The CATCH physiotherapist (PT) visits patients on inpatient units during daily team rounds to help identify which patients should be in the program upon discharge.
• Patients have a CATCH appointment time to return to hospital before they are discharged.
• When they first come to CATCH, they are assessed by the PT who develops an individualized reconditioning program for them.
• The RPN completes a risk assessment for the patient and also coordinates other services the patient may need based on this assessment (such as scheduling follow-up specialist or doctor’s appointments).
• The RPN follows up on any changes in medications patients have upon discharge. Medications are often added and/or subtracted during a hospital stay. The nurse makes sure that: there are no contra-indications; the patient fills all prescriptions at the same pharmacy; and the patient is following other safe medication practices.
• The RPN offers education on the patient’s condition and how to prevent deterioration. Some of the topics the nurse may cover include self-care, nutrition, pain management, fall prevention and healthy lifestyle.
• A medical internist will also assess the patient to look after any medical needs.
• The reconditioning program is delivered by an OTA/PTA and the RPN.
• At the end of three weeks, a reassessment is done by the CATCH team, and they decide if any further care is needed, including more time in the CATCH program or connecting patients with care in the community.