Challenges elderly patients face in hospital to home transition

Patients/caregivers shed light on challenges; community care partners already acting on input

A project in two regions of the province that captured the experiences and challenges of elderly patients moving from hospital to home or long-term care has already precipitated changes to improve those transitions.

Having Their Say and Choosing Their Way: helping patients and caregivers move from hospital to 'home', was funded by The Change Foundation in partnership with the Ontario Association of Community Care Access Centres (OACCAC). It was conducted in the South East CCAC and Quinte Health Care's Trenton Memorial Hospital in 2008 and in Toronto Central CCAC and Toronto Western Hospital in 2009. Reports on the project are being released today at www.changefoundation.com, along with a Commentary by The Change Foundation, informed by insights from project partners and highlighting changes implemented since the project wrapped up.

To view Commentary please visit: https://changefoundation.ca/

The research findings came from interviews conducted with 30 recently discharged patients and their caregivers and from observations drawn from shadowing key staff, tracking and analyzing the myriad steps in the trek from hospital to home, with services, or from hospital to long-term care. Having Their Say & Choosing Their Way is a quality improvement project so it focused on opportunities for improvement, not on all the successful transitions that occur each year. While patients and their families praised some providers and were grateful for the care, others found it unhelpful or insufficient. Many reported they were confused about the next steps in their care and uncertain where to turn for help, ill-informed about who would provide what services when, and unclear about the rules for placement in long-term care facilities. "It's sort of like a black hole you know," said one patient (see above link for more quotes).

"The Change Foundation invested in this project because timely, supportive transitions from hospital to "home" are key to high quality, efficient health care. The Foundation is also committed to looking at quality improvement through the eyes of patients and caregivers, and we've learned from their real-life stories that many of our efforts aren't paying off for them - or the system," said Change Foundation CEO Cathy Fooks. "We will use this work to redirect and redesign appropriate care around the particular needs of patients as they leave hospital and get on with their lives," says OACCAC CEO Margaret Mottershead.

The good news, says Fooks, is that the project is already having on-the-ground impact for patients, families and providers and points to ways to help alleviate systemic issues such as avoidable ER admissions and unnecessary hospital stays or alternate-level of care (ALC) days. "We commend the site partners for their commitment to quality improvement, patient input and public scrutiny to drive changes to support Ontarians in the midst of these life-changing transitions," say Fooks and Mottershead.

"This project, combined with others, was pivotal for the Toronto Central CCAC in challenging our thinking and behaviours," says Stacey Daub, Senior Director, Client Services from the Toronto Central CCAC. "It brought the voice of the client to our planning and it significantly informed our path forward. We have dramatically changed our approach to transitions with our hospital partners as a result."

"The study reminded us that we are caretakers of peoples' lives and futures," says Katherine Stansfield, VP, Patient Services, Quinte Health Care. "Each part of the system is responsible for a segment of the process, but it's a person's life we're affecting. We can't lose sight of that in the midst of stats and aggregate numbers."

Source: THE CHANGE FOUNDATION