In 2012, the Boards of the North East CCAC and the North Bay Regional Health Centre (NBRHC) held a face-to-face meeting to discuss opportunities for cooperation and collaboration. Every year since, the organizations have renewed a memorandum of agreement that sets out the terms of the organizations' working relationship, their joint commitment to improving patient service delivery, and the selection of specific measurable, attainable metrics for the year, which are reported to both boards.
This agreement has already led to successes in integrated discharge planning that saw length of stay for patients awaiting long-term care dramatically reduced. For 2015, a common goal was set for the achievement of timely referrals and assessments in order to improve patient transitions and care planning. Recent evaluation of those targets shows more improvement through collaboration.
Under this new initiative, the established target for the North East CCAC was for a 10% improvement on hospital inpatient assessments completed within assessment priority timelines, while the NBRHC's goal was a 10% improvement in the number of hospital inpatient referrals with greater than 24-hour notice of discharge.
There is a symbiotic relationship between the two metrics. If not enough notice is given of a patient's discharge date, care providers in the community may not be able to schedule visits when needed, delivery of equipment and supplies may be delayed, and planned assessments of other patients could be postponed. On the other hand, if patients are not assessed and discharged from hospital in a timely fashion, Emergency Department waiting times may start to increase, inpatient units could become overcrowded, and the cycle begins again.
"Together, we committed to identifying where we could improve on patient transitions," says Kerby Audet, Director, Care Coordination. "In a system of care, if one part goes off the tracks, it impacts another area. Acute care must create capacity, and we need to help them do that, which requires a systemic approach to solutions with all partners working together."
Care Coordination Manager Anna Bullock and her CCAC team in North Bay have worked closely with their NBRHC colleagues, conducting mutual education sessions and bi-weekly leadership meetings. Both teams monitor metrics on an ongoing basis, and enhanced resources have been dedicated to the effort.
The result? Hospital inpatient referrals with greater than 24-hour notice of discharge have exceeded the established target by 10% - a 20% improvement over the baseline data. Meanwhile, the North East CCAC also exceeded its 10% target improvement on hospital inpatient assessments completed within priority timelines.
"This success is a direct result of a methodical, steady approach to solving a complicated issue," affirms Audet. "Health care is never simple, and there are always external factors that impact your efforts. But by keeping patient-centred care at the forefront, and identifying and isolating issues that need to be addressed one at a time, we can improve how we work together, and improve patient care."
While this particular initiative is specific to North Bay, similar collaborative efforts are ongoing in hospitals across the Northeast, with both the CCAC and its acute partners determining local priorities that are specific to the challenges in each individual community.