A patient’s transition from hospital to home is a critical step in their healthcare journey. While there are services and supports in place to help make the transition smoother, certain barriers exist—such as delays in accessing appropriate services and bed gridlock—that can make navigating the system difficult for patients and their families.
At Runnymede Healthcare Centre, the patient flow team helps bridge this gap, making a patient’s transition from acute care through rehabilitation to home smoother. Through open communication with acute care hospital partners and a focus on providing patient- and family-centered care, Runnymede is not only helping to improve the flow of patients through hospitals, it is also responding to changing health care needs and reducing the strain on the system by freeing up beds and getting patients home sooner.
Partnering for seamless transitions
In order to improve patient flow and inform decision-making, detailed information on patients waiting in hospitals for alternate levels of care (ALC) is required. An ALC designation can be made, for example, after a patient has completed the acute phase of their care and is waiting to be transitioned to a more appropriate setting to receive the next phase of their treatment, such as rehabilitation.
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Runnymede has formal partnerships in place with both St. Joseph’s Health Centre Toronto and Trillium Health Partners to improve access to healthcare services for patients who need extended rehabilitation following treatment or surgery. When a bed is available in Runnymede’s Low Tolerance Long Duration Rehabilitation (LTLD Rehab) program, patients are transferred to the hospital to receive therapy. Constant and open communication with partner hospitals ensures patients receive the right care in the right place at the right time, freeing up much-needed acute care beds in the process.
“We value the open dialogue we have with our acute care partner hospitals,” begins Lisa Dess, vice-president of clinical programs. “Before a patient is admitted to our rehab program, we collect the necessary information about their health and hospital experience to date, and ask all of the important questions up front so we can make the most informed decisions regarding their care. Due to our strong working relationships with partner hospitals, much of this work is done ahead of admission. This ensures our interprofessional team gets to know patients and the type of care they need in advance of their arrival, allowing us to safely and seamlessly transition them to the next stage of their care.”
Big picture thinking on admission
Discharge planning is an important part of any admission as it plays a vital role in ensuring a smooth transition from hospital to home. Once a patient is admitted to Runnymede, they meet with their care team and discharge planning begins. From the get-go, patients and their family members and/or caregivers are provided with the support and resources they need to make decisions about their own care. Healthcare goals are also set with patients on admission and a comprehensive plan—including appropriate clinical and community-based supports, if necessary—is put in place for when the patient is ready and able to go home. Making discharge planning a part of the conversation early on helps build excitement about a patient’s future prospects and ensures that they are aware of the resources available to assist them as they transition to the next leg of their healthcare journey.
Responding to healthcare system needs
Some patients in need of rehabilitation following an acute care stay can face delays in accessing services. To ensure patients get the care they need in a timely manner, Runnymede’s patient flow team communicates bed availability to partner hospitals in advance. Not only does this help enhance planning and coordination at all hospital sites, it also facilitates more effective and efficient patient transitions, cutting wait times and freeing up beds. This process has also allowed Runnymede to make same-day admissions and discharges in many cases, which ensures the hospital continues to operate at full capacity, meeting the Toronto Central Local Health Integration Network’s (TC LHIN) standards.
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Runnymede is committed to making a patient’s transition from acute care through rehabilitation to home as seamless as possible. By working in close collaboration with partner hospitals and putting patients at the centre of their own care, the hospital has not only helped meet healthcare system needs, it has also been successful in coordinating many complex discharges, getting patients home sooner: since the start of Runnymede’s LTLD Rehab program in 2012, the hospital has successfully transitioned nearly 600 patients back into the community.
