Integrated postpartum discharge: New program follows identified high-risk


North York General Hospital (NYGH) and Saint Elizabeth Health Care (SEHC) are pleased to announce an exciting new partnership to provide identified high risk mothers, their babies and families with a seamless continuum of care, services and support from hospital to home.

As Ontario’s second largest single site birthing centre, NYGH helps bring over 5,000 babies safely into the world each year. The integrated postpartum discharge program will enable identified mothers and their babies to return home earlier – safely and confidently – with the support of an interdisciplinary team of health professionals, best practice care and linkages to community resources.

The objectives of the program are to provide individualized, high quality client-centred care, while maintaining shortened length of stay; providing cost-effective service in an appropriate setting; reducing re-admissions; increasing patient and provider satisfaction; and ensuring a safe experience.

Upon discharge from the hospital, NYGH will refer identified clients to Saint Elizabeth Health Care for follow-up care and support. A maternal newborn nurse will contact the family to conduct a telephone assessment. Based on this assessment, the nurse will schedule an in-home visit within the next 24 hours or a second phone assessment. During the visit, the nurse will perform an assessment of the mother and baby and provide hands-on care and teaching within the family’s home setting.

When required after the home visit, a follow-up phone call by the community nurse will help to identify any additional issues or concerns. Referrals to Public Health, CCAC or community support services will be made as appropriate, and the SEHC nurse will link with family physicians and obstetricians at NYGH for communication and follow-up.

The perinatal team at SEHC, which includes maternal newborn nurses certified in breastfeeding as well as lactation consultants, has the knowledge and skills to meet the unique and diverse needs of childbearing women and families, including multicultural and high-risk populations. The program is expected to serve more than 2,800 clients per year.

“This partnership stands as a great example of how health care organizations can be working together in new and innovative ways to deliver high quality, responsive care and services along a continuum,” says Shirlee Sharkey, President and CEO of Saint Elizabeth Health Care. “Both of our organizations have established a reputation of excellence in maternal newborn care, and together, we’re able to raise the bar even further.”

The program builds on the success of a similar prior collaboration between NYGH and SEHC, which consistently achieved high marks from new mothers on client satisfaction surveys.

“We are thrilled to be able to offer our identified at-risk moms a comprehensive follow-up program,” says Nazira Jaffer, Program Director, Maternal Newborn and Paediatric Programs at North York General Hospital. “In partnership with Saint Elizabeth Health Care, we are able to offer these moms a safe and seamless transition back into the community.”

For more information about the program, please contact (416) 756-6287.