With nearly two thirds of the Region’s 90 Days of Innovation Ready Every Day complete, the Community Strategies team (Team 1) is working hard to put processes in place to prevent the need for some people to seek emergency and acute care.

Team 1 at a recent open house.

Team 1 is working in three sub-teams on specific parts of their plan.

“The work of our team is two-fold,” says team lead Corey Miller. “To provide services in the community that will prevent emergency department visits and hospital admissions, and to provide the services needed to safely transition people from the hospital and back to their homes or a home-like environment.”

The team is comprised of three sub-teams, including:

 Tammy Vornbrock, Community Expansion

Vornbrock’s team is focused on exploring initiatives that will reduce patient days in hospital by providing the appropriate supports to patients who can reduce their length of stay in hospital and safely transition back into the community. The team is also looking at initiatives that enhance support in the community to avoid future admissions. Three of the top five reasons for admission to acute care from long-term care and personal care homes are: pneumonia, urinary tract infections and sepsis.  This equates to 3,328 patient days annually. By offering safe support in the community, this number can be reduced by 50 per cent, which would equate to nine beds annually.

The goals of the team are:

  • To expand the Home IV Therapy program in the community.
  • To explore the option of implementing a community-based Total Parenteral Nutrition (TPN) program. TPN is for patients who cannot get their nutrition from eating.
  • To expand the Direct Client Funding program, which provides an alternative to long-term care.
  • To implement community pathways around the Region’s top three reasons for admission to acute care from long-term care or personal care homes.

The interprofessional groups engaged on the team include:

  • Pharmacy
  • Lab
  • CPAS: Manager, Client Care Coordinators and Direct Client Funding Coordinators
  • Physicians
  • Critical Care Associates
  • Regina TPN Program leaders
  • Long-term Care Homes
  • Occupational Therapy
  • Clinical Dieticians
  • Nursing Managers
  • Home Care
  • Community Nurse Practitioners
  • Chronic Disease Management
  • Professional Practice
  • Practice, Education and Research

Albert Matthies, Alternate Level of Care

Matthies’ team is focused on strategies to provide alternate levels of care to patients who are in hospital, but who no longer require the intensity of care a hospital provides. His team is working to understand patients’ alternate needs in the early stages of their recovery, and to help healthcare workers navigate these patients through their alternate needs and back into the community. Alternate needs may include: reduced mobility, cognitive impairment, behavioural issues, addictions issues, inability to manage personal care, 24-hour care or supervision required, inability to manage meds, IV meds required, no support at home, caregiver fatigue, homeless, etc.

The goal of the team is threefold:

  • To assist staff in identifying the post-hospital needs of patients while they are recovering in hospital.
  • To create a visual, electronic dashboard to enable staff to facilitate linkages between patients who require alternate care and the community partners able to provide this care. Community partners may include long-term care homes, personal care homes, home care, restorative care, respite care, palliative care, rehabilitation, transition locations, etc.
  • To identify community partners who offer the specific care patients’ require and to work collaboratively with these partners to pull patients from acute care and back into the community when appropriate.

The interprofessional groups engaged on the team include:

  • All adult inpatient unit staff (e.g., registered nurses, licensed practical nurses, CPAS [Client Patient Access Service] coordinators, occupational therapists, physical therapists, registered dieticians, social workers, speech language pathologists)
  • All of the Region’s 30 long-term care homes
  • All personal care home partners
  • Home Care/Home First staff
  • Community mental health and addiction partners
  • Client Patient Access Services in the community
  • MD Ambulance
  • Team 3: Information and Decision Support

 Lisa White, Client Patient Access Services

White’s team is the link between the Community Expansion and Alternate Level of Care teams. Client Patient Access Services (CPAS) is the single point of contact for patients to access services in the community (e.g., Home Care, physical therapy, social services). CPAS coordinators work with patients to create care plans to meet each patient’s individual needs pre- and post-hospital. But as patients flow from the community to hospital and back into the community, they pass through multiple departments and agencies, and experience many handoffs and handovers. Challenges that exist include multiple layers of re-work, little to no communication between healthcare providers at different points in the system, and lack of continuity of care for patients.

The goals of White’s team are:

  • To understand the complex process of accessing community services both pre- and post-acute care.
  • To help clients make a smooth transition to progressive levels of care in the community, allowing them to avoid unnecessary admissions to acute care.
  • To make this process visible to help all care providers identify where improvements need to be made and what steps to take to ensure a smooth flowing system.

The interprofessional groups engaged on the team include:

  • CPAS Acute
  • CPAS Community
  • CPAS Quick Response (for non-acute services)
  • Home Care
  • Therapies (e.g., occupational, physical)
  • Unit clinical coordinators

The goal of these many community strategy initiatives is to provide the right care, at the right time, in the right location for every client who we serve. It is anticipated that these strategies will enable resources to be re-allocated from acute care and into the community setting.

See more stories about Region improvements at www.saskatoonhealthregion.ca/ReadyEveryDay.