1. Example Patient Journeys
The following scenarios illustrate some of the barriers and challenges faced by six typical patients in our system. What follows is a description of their journey in the current state and how that process will be improved through implementation of the WRHA clinical consolidation plan.

2. Surgery Journey Mr. T’s Journey – Pre Consolidation
Mr. T calls 911 with severe abdominal pain and a potential bowel obstruction
Paramedics perform assessment in the home. Dispatch considers  patient needs, paramedic protocols and current ED status to determine where to take Mr. T
Mr. T waits several hours until his first assessment due to a busy ED
Mr. T is discharged five days later
Five days later
Operator asks Mr. T for medical details and his address. Mr. T lives in the Seven Oaks General Hospital area
Paramedics determine Seven Oaks can see him most quickly. Mr. T is brought to Seven Oaks General Hospital
Mr. T needs surgery. He is transferred to Grace Hospital

3. Mr. T’s Journey – Post Consolidation
Mr. T calls 911 with severe abdominal pain and a potential bowel obstruction
Paramedics perform assessment in the home. Dispatch considers  patient needs, paramedic protocols and current ED status to determine where to take Mr. T
Mr. T is promptly assessed due to ED processes instituted
Mr. T is discharged five days later
Five days later
Operator asks Mr. T for medical details and his address. Mr. T lives in the Seven Oaks General Hospital area
Paramedics determine Grace Hospital is best site option for patient needs. Mr. T is brought to Grace Hospital
Mr. T needs surgery. He receives surgery later the same day at Grace Hospital

4. Mental Health Journey Mrs. B’s Journey – Pre Consolidation
Mrs. B arrives at Grace Hospital ED with depression and suicidal thoughts, Friday at 7:05 p.m.
Mrs. B is assessed by psychiatric emergency nurse (PEN) and an Emergency Physician
8:25 p.m. Emergency physician decides psychiatric consult is needed and calls CRC to arrange apt.
Mrs. B is transferred to the Crisis Response Centre for assessment at 9 a.m. Saturday morning.
Mrs. B is transferred back to Grace Hospital emergency to await inpatient bed Saturday 11 a.m. and remains there until transfer
Mrs. B is transferred to HSC inpatient bed at 2 p.m. Monday
Admission required but no beds available
Total of 3 transfers

5. Mrs. B’s Journey – Post Consolidation
Mrs. B arrives at Grace Hospital ED with depression and suicidal thoughts, Friday at 7:05 p.m.
8:25 p.m. Emergency team decides psychiatric consult is needed and calls CRC for assessment
Mrs B Requires admission
Total of 1 transfer
Advantage in post consolidation- one less patient transport- may not make a difference in timing of consultant availability ( at present – I am not certain MH has capacity to do 7 day a week telehealth – but this would need to be known as an absolute)
Mrs. B is assessed by psychiatric liaison emergency nurse and an Emergency Physician at Grace Hospital
Mrs. B receives psychiatric assessment via telehealth at 8:30 p.m. from CRC psychiatrist
Mrs. B is transferred to HSC inpatient bed when bed becomes available

6. Care for the elderly Mr. G’s Journey – Pre Consolidation
Mr. G is an 85 year-old living in the community with symptoms of delirium and mobility issues.
Mr. G. presents to St. Boniface Hospital ED with symptoms of delirium
Mr. G transferred to CAU for further assessment. Specialty services not required and no additional acute care needs
Mr. G waits another 30 days for placement into an available PCH bed
Patient placed into PCH 34 days following presentation to ED
Urgent concerns managed in ED but further symptom management is required for full recovery
Remains in CAU for 3 days before being admitted to an inpatient bed with a potentially treatable delirium.
Discussion with care team and family in ED notes Mr. G will be headed to PCH after acute care stay

7. Priority Home Philosophy Mr. G’s Journey – Post Consolidation
Mr. G is an 85 year-old living in the community with sudden confusion and mobility issues.
Mr. G is transitioned to Transitional Care in 4 days upon being deemed medically stable and ready for discharge home
Mr. G. presents to St. Boniface Hospital ED with symptoms of delirium
Care team determines a safe return home not ideal due to continued mobility issues. Further time for restorative/ convalescent care needed
Urgent concerns managed in ED but further evaluation is required Specialty services not required and no additional acute care needs
Care teams discusses the discharge plan with family - care to be provided in transitional care environment with goal to return home noted post stay in transitional care

8. Community Care of the Elderly Mr. F’s Journey – Current
Mr. F is a home care client with osteoarthritis, congestive heart failure and chronic obstructive lung disease.
Mr. F goes to the emergency department with acute pneumonia
Mr. F is paneled for PCH placement
33 day wait
Mr. F cannot move about independently because his functional needs are very high. His family is not confident they can support Mr. F at home
Mr. F is admitted to a personal care home after 33 days in hospital

9. Mr. F’s Journey – Post Consolidation
Mr. F is a home care client with osteoarthritis, congestive heart failure and chronic obstructive lung disease.
After 70 days Mr. F no longer needs Priority Home. He goes back to receiving regular home care and avoids going to a personal care home
Mr. F goes to the emergency department with acute pneumonia
The hospital team consults hospital home care staff. Home care staff assess Mr. F as a candidate for Priority Home
Discharged home in 15 days
Mr. F loses some of his ability to move independently. His family is not confident they can support Mr. F at home
Mr. F returns home after 15 days in hospital and receives Priority Home service for 70 days

10. Home and Primary Care Mrs. Q’s Journey – Current
Mrs. Q lives in the community with poorly controlled diabetes.
Mrs. Q remains in ED for one or two days and is discharged home with instructions regarding the management of her diabetes and instructions regarding insulin dosages
Mrs. Q presents to Grace ED with hyperglycemia nearly every week
Mrs. Q returns to Grace ED with hyperglycemia eight days later and undergoes the same process
Grace stabilizes her hyperglycemic state
Mrs. Q returns home, unable to follow the medical advice given in hospital on her own without support

11. Mrs. Q’s Journey – Post Consolidation
Mrs. Q lives in the community with poorly controlled diabetes.
The hospital team consults hospital home care staff. Home care staff assess Mrs. Q as a candidate for Rapid Response Nursing (RRN)
RRN works with Mrs. Q to connect to her family physician and pharmacy. The RRN supports Mrs. Q and teaches her how to manage her diabetes
Mrs. Q presents to Grace ED with hyperglycemia nearly every week
Mrs. Q no longer attends the emergency department as she is now able to manage her diabetes with supports in the community
Grace ED stabilizes her hyperglycemic state
Mrs. Q returns home while a Rapid Response Nurse visits her at home daily beginning after discharge from hospital

12. Cardiac Sciences Mr. X’s Journey – Current
Mr. X is a 68-year-old presents to SOGH emergency with palpitations and diagnosed with typical atrial flutter
Several medication combinations are trialed in hospital, then physician refers him to outpatient cardiology
Mr. X waits three months to receive the cardiology care he needs
10 days hospital stay
Within 24 hrs
3 months later
Mr. X is admitted by a family physician
Mr. X visits arrhythmia service at St. Boniface Hospital which includes cardioversion
Cardioversion: Restoration of a normal heart rhythm in a patient with an abnormal heart rhythm
Ablation: Catheter based procedure to destroy abnormal electrical tissue in the heart

13. Mr. X’s Journey – Post Consolidation
Mr. X is a 68-year-old presents to SOGH Urgent Care with palpitations and diagnosed with typical atrial flutter
Mr. X is admitted to St. Boniface General Hospital under the care of a cardiologist
Within 24 hrs
Within 24 hrs
Within hrs
Mr. X is transferred to emergency at St. Boniface. He consults with a cardiologist from the Cardiac Sciences Program (CSP)
Mr. X receives arrhythmia service within 24 – 72 hours (when he would normally be discharged) which includes cardioversion and consult for ablation
Cardioversion: Restoration of a normal heart rhythm in a patient with an abnormal heart rhythm
Ablation: Catheter based procedure to destroy abnormal electrical tissue in the heart