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Collaboration Across the
Continuum of Care
Canadian Quality Congress
September 19 & 20, 2016
Mareika Purdon
Michelle Wallace
Gail Aguillon
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The Glenrose Rehabilitation Hospital
• Largest free standing
tertiary rehabilitation
hospital in Canada
• 244 inpatient beds
•1,714 inpatient visits/yr
• 79,740 outpatient
visits/yr
• Average length of stay =
36.8 days
3
Presentation Objectives:
1) Identify the positive impact that a multidisciplinary team
coordinating across the continuum of care can have on
patient/family transitions in care
2) Demonstrate the complexities of our healthcare system
through the eyes of our patients/families
3) Articulate a Patient & Family Centered Approach to
setting goals for care and seamless patient transitions
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Collaboration: Spinal Cord & Brain Injury
• Spinal Cord Injuries (SCI) and Brain Injuries (BI) can
have a devastating impact on both the health and social
well-being of people.
• Timely and effective care from injury, through the acute
phase, to rehabilitation is crucial in terms of survival,
neuroprotection, prevention of secondary complications,
and psychosocial adjustment.
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Opportunity
• In the EZ we have work underway to optimize the
transition of our patients across the continuum.
• Teams from across the zone are
collaborating to become more involved in
the patient’s discharge process early in
their care.
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Discharge Considerations
• Patient and family education & support
• Community support and resources
• Home modifications or alternate living arrangements
• Specialized equipment
• Homecare or self-managed care
• Vocational support
• Financial resources to initiate the
discharge preparations and sustain
their future
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Key Partners
Patients & Families Transitions Services
Neurosciences Quality Council IFM
Community Agencies Primary Care
Frontline Teams (GRH, RAH, UAH) Continuing Care
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The Patient Journey
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Priorities Identified by Frontline Staff
Communication
Roles &
Responsibilities
Patient Care
Path & Quality
Process
Standardization
Community
Partnerships &
Integration
Patient &
Family Centred
Care
Physician
Processes &
Communication
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Alignment with Current Priorities & Work
Underway
• Patient First Strategy: Patient Transitions
• Accreditation: Patient Transitions ROP
• Destination Home
• CoACT: Integrated Plan of Care
• Seven Days/Week Service Delivery
• Change Day!
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Evaluation:
• Patient Experience Surveys
• Staff Feedback
• Patient’s Length of Stay in each phase of Care
• Addressing & Removing Barriers to Discharge to Home
or into Community Living Options/Facilities
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Sharing Learnings & Spread
• Key learnings and new processes that arise will be
shared with stakeholders throughout the Zone for
spread within other programs for example: Stroke,
Geriatric Psychiatry
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References
• Accreditation Canada. (2016). Required organizational practices handbook 2016,
Version 2. Retrieved from: https://accreditation.ca/sites/default/files/rop-handbook-
2016v2.pdf
• Agency for Healthcare Research and Quality. (2013). Care transitions from hospital
to home: Ideal discharge planning. Retrieved from:
http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy4/inde
x.html
• Alberta Health Services. (2015). The patient first strategy. Retrieved from:
http://www.albertahealthservices.ca/assets/info/pf/first/if-pf-1-pf-strategy.pdf
• Coleman, E.A. (2003). Falling through the cracks: challenges and opportunities for
improving transitional care for persons with continuous complex care needs. J Am
Geriatr Soc. 51(4):549-555.
