The professionals who plan patients’ discharge from Sudbury Regional Hospital, and the North East Community Care Access Centre (CCAC) workers who decide whether these patients should receive home care or be placed in a long-term care facility, will soon be working more closely together.
As part of the implementation of the Home First program, which would see more patients who no longer need acute care being sent home from hospital with enhanced home care supports, the hospital and the North East CCAC are integrating some of their operations.
The Home First program aims to reduce the number of alternate level of care (ALC) patients in the hospital, or those who no longer need acute care, but are unable to find appropriate care in the community.
The North East CCAC is in the process of hiring a director of integrated discharge services, who would be in charge of clinical reviewers and social workers at the hospital, along with case managers at its own organization.
Kim Morris, a spokesperson for the North East CCAC, said the job will likely be posted soon, and she hopes to have the new director in place by mid-October.
“We’re really hoping that this position will assist with that whole ALC issue that’s been at the forefront and a challenge,” she said. “It’s to really look at discharging those patients (from hospital) quickly and appropriately.”
Dave McNeil, the hospital’s vice-president of clinical programs and chief nursing officer, said both the hospital and the North East CCAC, individually, do an “excellent job.”
... a good discharge plan will actually keep the person in the community longer, and keep them healthier.
Dave McNeil,
vice-president of clinical programs and chief nursing officer, Sudbury Regional Hospital
The new director of integrated discharge services will just help the two organizations to develop a “seamless process,” he said.
“If there’s issues, from our side, they won’t flow up through the organizational structure to me, and I won’t have to pick up the phone and phone the CCAC and say, ‘We have these little issues, and we need to work it through,’” McNeil said.
“That integrated director will be empowered to deal with all the issues between both organization, and make the decisions around what’s best for the patient, and make the system the most efficient.”
McNeil said discharge planning is “absolutely crucial.”
“All research shows that if you have effective discharge planning, patients are happier, families are happier, and the system can be more efficient,” he said.
“More importantly, a good discharge plan will actually keep the person in the community longer, and keep them healthier.”
The Home First program is being implemented in the four major centres in the northeast — Sudbury, Sault Ste. Marie, North Bay and Timmins.
The program has been ramping up in Sudbury over the last few months, and should be fully operational soon, Morris said.
McNeil said he doesn’t expect Home First, by itself, to solve the hospital’s ALC crisis. He there are several initiatives underway to help alleviate some of the pressures on the hospital, and together, they should make a difference.
“There’s no silver bullet in this process,” he said. “This is all incremental, and we need to make hundreds of these incremental improvements, and then add the appropriate resources within the community to actually care for these people.
“That’s where people want to be cared for. They don’t want to be cared for in the hospital.”
