1. Innovative practices in transitions between hospital and home: Recommendations in support of advancing a Health Links approach
A presentation to the Embracing Leadership, Engagement and Transformation
Primary Health Care Forum 2016
Agnes Gibson, Regional Quality Improvement Specialist
Susan Taylor, Director Quality Improvement Program Delivery
October 6, 2016
Health Quality Ontario
The provincial advisor on the quality of health care in Ontario

2. Faculty/Presenter Disclosure
Name of Presenter(s): Susan Taylor & Agnes Gibson
Relationships with Commercial Interests: NONE
Grants/Research Support: NONE
Speakers Bureau/Honoraria: NONE
Consulting Fees: NONE
Other: NONE

3. Disclosure of Commercial Interests
This presentation has received financial support from: NONE
This presentation has received in-kind support from: NONE
Potential for Conflict of Interest: NONE

4. Learning Objectives
Learn about a systematic approach to the identification, assessment, selection and dissemination of innovative practices in order to:
Champion effective local innovation among Health Links;
Enable performance improvements among all Health Links based on evidence-informed and experience-based practices; and
Provide information on how to implement innovative practices and connect communities.
Describe the opportunities for family physicians and primary care practices to leverage these approaches to improve the care experience for patients living with multiple conditions and complex needs

5. Supporting the Advanced Health Links Model
Improving integrated care for patients with multiple conditions and complex needs
MOHLTC
LHIN
Sets the strategic direction for Health Links
Provides overall funding to the LHINs
Oversees the overall performance of the Health Links initiative to guide strategy
Facilitates operational success by implementing provincial level tools and supports
Sets regional priorities for Health Links and ensure alignment with provincial priorities
Funds Health Links in accordance with priorities
Maintains overall accountability for Health Links performance, LHIN by LHIN
Drives operations through implementation of plans and support for adoption of provincial tools
Identifies and implements regional supports and tools as required
Health Quality Ontario
Support data collection, timely reports and analysis
Lead systematic identification of emerging innovations and best practices
Increase rate of progress through standardization of best practices across all Health Links
Support inter-Health Link sharing of lessons learned on regional or pan-provincial basis
Connect LHIN HL Leads with other relevant provincial quality initiatives

6. Quarterly Reports
Circulated broadly with full transparency among Health Links
Includes:
Self reported data on two key measures (Coordinated Care Plans and attachment to Primary Care Providers)
Local and provincial targets
Summaries of discussion on how Health Links are approaching
Patient stories
Future reports will include uptake of innovative practices endorsed by the Clinical Reference Group

7. Impact of Health Links – Q1 Update
06/12/2018
Impact of Health Links – Q1 Update
Coordinated Care Plans
Access to Primary Care
22,707 complex patients have been provided with coordinated care plans through Health Links
34,072 Health Links patients have been connected to regular and timely access to Primary Care
Data Source: Health Quality Ontario’s Quality Improvement Reporting and Analysis Platform (QIRAP) – self-reported by Health Links
Health Quality Branch

8. Clinical Reference Group
The Clinical Reference Group (CRG) is an
action-oriented, functional body, designed to assess the quality of evidence, impact, and spread of existing practices within the
Health Links
for the purposes of identifying suitability and readiness for wide scale spread.

9. Innovative Practices Evaluation Framework

10. Innovative Practices Evaluation Framework
Systematic review of innovative practices, with consideration of:
Quality of the evidence
Impact/Results
Spread
Possible recommendations include:
• Not at this time
• Targeted spread within specific contexts
• Provincial spread, with 1 year reassess using Innovative Practices Evaluation Framework
• Large scale provincial spread
Attachment: Innovative Practices Evaluation Framework - overview

11. That advises on what (and why and who and how) and when
A Continuum…
Quality Standards
That advises on what (and why and who and how) and when

12. Transitions between hospital and home
An important part of providing coordinated care to patients is improving patient transitions within the system to help ensure patients receive more responsive care that addresses their specific needs.

13. Assessing Innovative Practices

14. Transitions from Hospital to Home
The approach to effective Transitions from Hospital to Home can be outlined as follows:

15. Example 1:

16. Links to
Click

17. Transitions between Hospital and Home

18. Evidence-Informed Best Practices
Steps for Transitions between Hospital and Home
Evidence-Informed Best Practice
(cited in Quality Compass*)
Early in the Hospital Admission
Perform medication reconciliation on admission
Assess patient risk of readmission
Assess health literacy
Throughout the Hospital Stay and Transition Process
Use teach back when building caregiver and patient capacity
Enhance patient and caregiver communications with the use of visual tools
Close to the Time of Discharge
Ensure personal clinician to clinician transfer
Perform medication reconciliation at discharge

19. Innovative Practices Endorsed by CRG