Improving the Transition from Hospital to Home or Community-based Care
DISTRICT OF THUNDER BAY
Thunder Bay Service Collaborative
What is the system challenge?
When transitioning from inpatient hospital care to home or community-based care, people with mental health and addiction challenges can ‘fall through the cracks’. The first days and weeks following psychiatric discharge are particularly fraught periods. People can relapse. They’re also more vulnerable to suicide (Chung et al., 2017). Proper follow-up care (Kalseth et al, 2016) and social support (Donisi et al., 2016) within their community, however, can reduce this risk as people transition from hospital to community care.
Evidence from Ontario shows that timely transitions from hospital to community care are associated with lower hospital readmission rates and lower costs to the health system (Rahman et al., 2018).
What are we doing about it?
Service Collaboratives were established throughout Ontario to support local systems to improve coordination and access to mental health and addictions services. The District of Thunder Bay Service Collaborative, supported by CAMH’s Provincial System Support Program (PSSP), came together and identified the transition from inpatient mental health services to community care as a system gap requiring attention. The District of Thunder Bay Service Collaborative is made up of local service providers covering the City of Thunder Bay and the District of Thunder Bay (including Nipigon, Greenstone, Marathon, Manitouwadge and Terrace Bay).
To learn more about this gap, a team from PSSP’s Thunder Bay office led engagement sessions with stakeholders from 19 communities across the district and with persons with lived experience. The three major barriers to effective transition planning were system fragmentation, ineffective communication, and the absence of a standard consent process to share client information within the circle of care. The Service Collaborative identified several opportunities for system improvement, including:
The development of a specific hospital to community discharge protocol;
Formal communication and care pathways;
A process to obtain consent for sharing client information within the circle of care; and
Maintaining connection with client throughout follow up care.
To promote patient-centred care, the Service Collaborative recommended that solutions consider:
Potential challenges for people transitioning from an urban hospital back to a district community;
Support needed for clients to navigate the system; and
Privacy legislation.
The Service Collaborative elected to develop an evidence-informed Hospital Discharge Planning Protocol to ensure more consistent communication between the Thunder Bay Regional Health Sciences Centre (TBRHSC) and the clients’ home communities.
The TBRHSC and three family health teams are in the initial phase of implementing the Discharge Planning Protocol in district communities. This new process is intended to support people when they are often most vulnerable, such as during the transition from in-patient adult mental health hospital treatment back into their homes and communities.
Evidence:
A scoping review of evidence by Storm et al (2019) demonstrated the benefits of coordinated care during transition from inpatient mental health treatment to the community. It showed that a coordinated discharge process can improve service uptake, social functioning, and awareness of available resources among people with severe mental illness. The review also discussed interventions involving several components, making it challenging to determine which parts of the programs were most effective. Discharge planning appears to be a promising intervention to reduce clinical symptoms and increase quality of life.
More research is needed to learn more about how discharge planning interventions can be applied to populations with different needs. The scoping review did not include studies of adults with multiple medical conditions, immigrant or homeless populations, or children, youth, and older adults.
In addition, the National Institute for Health and Care Excellence (NICE) has published guidelines to support the transition between hospital and a community/home care setting for adults with social care needs (NICE, 2015). The guidelines are based on the best available evidence. They provide several recommendations to improve the patient experience, from admissions to discharge:
Establish communication protocols and procedures that support admissions.
Develop a hospital-based multidisciplinary team upon admissions, according to client needs.
Assign one health or social care provider responsible for transition/discharge planning and for communicating with health care providers, social care practitioners, the client, and their family.
Ensure all organizations are in agreement with the discharge planning protocol.
Establish a process to identify factors that could impede a safe and timely transition from hospital.
Communicate discharge and follow-up plan with all care providers within 24 hours of discharge.
Arrange follow-up care for the client within 7 days, or 48 hours, if there’s a risk of suicide.
The NICE guideline on the transition between inpatient mental health treatment and community or home care (NICE, 2016) recommends that when clients are admitted to a hospital outside of their home community, their transition plan should include a care provider from their home community. It’s important to support clients in order to maintain social relationships, and to stay connected to their occupational, recreational or educational communities.
In addition, tools and resources and Quality statement 3: Communication on discharge can support organizations working to improve the transition from inpatient mental health to community for clients.
Full guideline:
Transition between inpatient mental health settings and community or care home settings
Who is involved?
PSSP’s Thunder Bay team will apply a health equity lens at all stages of the implementation process. This includes the voices of Indigenous and Francophone communities, as well as people with lived experience of mental health challenges. Participating organizations include:
Greenstone Family Health Team (Geraldton, Longlac)
Marathon Family Health Team
North Shore Family Health Team (Terrace Bay, Schreiber)
North of Superior Programs (Geraldton, Longlac)
Thunder Bay Regional Health Science Centre
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During the exploration stage, the Service Collaborative met with the Northwest PSSP team over several months to discuss current gaps in the mental health and addictions system. They observed significant challenges with individuals transitioning from inpatient hospital care to home or community-based care. The collaborative members then discussed possible interventions to improve the transition to the community following hospital discharge, as well as to determine pilot sites and clarify participation.
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Throughout the installation phase, the Service Collaborative worked closely with the initial implementing site to develop a discharge planning protocol. Providers were engaged throughout the process to promote ownership and to ensure their new protocol would meet community needs and be implemented with fidelity.
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The TBRHSC and three family health teams have started using the Hospital to Community Discharge Planning Process. Using fidelity checklists and regular coaching calls, the Thunder Bay PSSP team will monitor the implementation process and perceived effectiveness of the protocol, making changes as needed.
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The project has not yet reached this implementation stage.
Next Steps
The Service Collaborative Intervention Team will continue to pilot the discharge protocol with the hospital inpatient mental health unit and with the three district family health teams. Monthly coaching calls will allow the team to speak to the successes and challenges that they experience. The team will complete fidelity checklists for evaluation purposes and for the purpose of keeping track of how the protocol performs in action. With the support of a Health Equity Coach, the team will conduct a Health Equity Impact Assessment of the discharge process. Evaluation findings will be reviewed regularly and discussed, and protocol changes will be made as necessary.
For more information, please contact:
Jennifer Kennedy, Implementation Specialist
Thunder Bay
(807) 626-9145 ext. 77209
References
Chung, D.T., Ryan C.J., Hadzi-Pavlovic, D., Singh, S.P., Stanton, C., Large, M.M. (2017). Suicide rates after discharge from psychiatric facilities: A systematic review and meta-analysis. Journal of the American Medical Association Psychiatry, 74(7):694-702
Donisi, V., Tedeschi, F., Wahlbeck, K., Haaramo, P., Amaddeo, F. (2016). Pre-discharge factors predicting readmissions of psychiatric patients: A systematic review of the literature. BMC Psychiatry, 16:449
Kalseth, J., Lassemo, E., Wahlbeck, K., Haaramo, P., Magnussen, J. (2016). Psychiatric readmissions and their association with environmental and health system characteristics: a systematic review of the literature. BMC Psychiatry, 16:376
Rahman, F., Guan, J., Glazier, R.H., Brown, A., Bierman, A.S., Croxford, R., Stukel, T.A. (2018). Association between quality domains and health care spending across physician networks. PLoS ONE, 13(4): e0195222.
Storm, M., Lunde Husebø, A.M., Thomas, E.C., Elwyn, G., Zisman-Ilani, Y. (2019). Coordinating mental health services for people with serious mental illness: A scoping review of transitions from psychiatric hospital to community. Administration and Policy in Mental Health and Mental Health Services Research, 46:352-367