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Program linking hospital staff to home-care workers pays off

Kinesiologist Tessa Philip, right looks in on Ilene Mulholland, left, during her work ou at the North Hamilton Community Health Centre, in Hamilton on Friday, February 12, 2016.

Orthopedic surgeon Anthony Adili says it used to feel as if he discharged his patients into a "black hole." Often elderly and with multiple medical conditions, the hospital's connection to their treatment, aside from routine follow-up appointments, mostly ended when they went out the door.

That changed when Hamilton's St. Joseph's Heath Centre, where he is chief of surgery, decided to try something different, linking health-care providers in the hospital to their counterparts in the community and giving patients a way to keep in touch and ward off complications that might lead to readmissions and emergency-room visits.

"Now I have no qualms about discharging a patient," Dr. Adili said. "The raft has a tether and patients know they can pull it any time."

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A home-care program that has staff in the hospital and in the community working as a single team sounds like a simple idea. But in the fragmented world of health-care delivery, this Hamilton experiment shows how much is needed for even common-sense changes to happen. With the Ontario government pledging to reshape its troubled home-care system and the federal government promising billions in new investment, the pioneers of this program say theirs is a model for others to follow as more care shifts from hospital to home.

Here's how it works. The approach, called "bundled care," because hospital and home-care dollars are combined and tied to individual patients, started four years ago in Hamilton partly because of the unique collection of services run by one organization. The hospital is part of the St. Joseph's Health Care System, which happens to include a home-care agency, making collaboration easier. It began as a three-year pilot that has now been renewed and targets three groups – those undergoing lung-cancer surgery, hip and knee replacements and those with chronic obstructive pulmonary disease (COPD) or congestive heart failure.

Home care in Ontario is now under review by the province, but generally is co-ordinated by a separate agency. Care for a single individual can involve a number of contract staff, sometimes from different providers. Under this model, hospital staff and community workers are a single team. Nurses, personal support workers and other professionals making home visits have weekly rounds to share information. They treat clients with similar conditions and get training and support from the hospital, so they gain expertise and know, for instance, when a picture of a wound might need to be sent to a care co-ordinator for a doctor to review.

Each patient leaves the hospital with a 1-800 number that puts her in touch with a member of the care team who has access to her records 24-7 – a safeguard program managers say everyone tests.

Kevin Smith, head of St. Joseph's Health System and an enthusiastic promoter of the model, says there is no reason it can't be replicated. He is proposing expanding it to all of St. Joe's patients who need home care and wants to put care co-ordinators in the emergency room so they can arrange supports to avoid hospital admissions in the first place.

"Doctors like it better, patients like it better, even health-care administrators like it," he said, quoting a former provincial health minister.

By keeping patients out of emergency rooms and allowing them to go home sooner, it also allows scarce health dollars to go further. Results from the St. Joe's pilot show patients spent fewer days in hospital, were less likely to be readmitted and when they were, it was for shorter periods.

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Ilene Mulholland, a patient in the program, figures early intervention measures have kept her out of hospital on two occasions. Ms. Mulholland, 79, who has COPD and is on oxygen, said that her home-care team has twice activated her "action plan," when she has had difficulty breathing, changing medications based on standing orders. She also has called to ask someone to "pop by" to check her chest. "It gives you a sense of security" she said. "It means a lot."

The bundle-care model is being expanded to nine hospitals at 22 sites in the Hamilton area for patients with COPD and congestive heart failure – about 2,400 annually. It also is being used in Kitchener-Waterloo by another hospital in the St. Joe's network.

Queen's Park is supporting other bundled-care pilots across the province, although some do not include all the elements of the St. Joe's model, such as the round-the-clock 1-800 number.

Donna Cripps, CEO of the local health agency that includes Hamilton, said the aim is to gradually "scale and spread" the model across the region with hospital and physician support.

For decades, she said, health-care funding has gone to the provider rather than the people in need of care. Under this model, money is "carved out" of hospital and home-care budgets and directed to patients. "It really is a fundamental change in the way we look at funding health care," she said. "To me that is the difference."

Dr. Adili at St. Joe's says improvements are still needed, such as more training for home-care staff, but he never wants to return to the old system in which he had no idea of the level of care his patients would get in the community and where live interaction with home-care staff was almost non-existent.

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"It almost feels embarrassing we didn't do it sooner," he said. "It is so simple."

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Toronto City Hall bureau chief



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