Speaker
Description
St. Peter’s is a 221-bed long-term care (LTC) home in Hamilton, Ontario, operated by Thrive Group. As a not-for-profit organization, it is guided by a philosophy that living well is enhanced through research, evidence-informed practice, and an integrated model of care tailored to individuals with unique needs. Despite this approach, gaps in communication between hospitals and LTC home were identified following resident readmissions after significant hospital stays. These gaps contributed to inconsistencies in follow-up care, missed referrals, and misalignment between hospital recommendations and residents’ goals of care.
The 72-Hour Post-Readmission Template Initiative was developed to strengthen interdisciplinary collaboration and improve post-hospitalization follow-up, particularly following prolonged or complex admissions. Key objectives included aligning care decisions with resident preferences and enhancing the experience of residents and families during care transitions. The initiative also targeted missed referrals communicated through external systems such as MyChart.
To inform this work, the team reviewed recent hospitalization experiences, gathered feedback from residents, families, and care providers, and analyzed trends in communication breakdowns. As a BPSO, St. Peter’s implemented the Transitions in Care BPG to improve continuity and reduce preventable transfers. Data from the preceding six months of emergency transfers were examined to identify system gaps, and residents and families were engaged to inform improvement strategies.
Implementation included a standardized 72-hour post-readmission care conference template, enhanced interdisciplinary engagement, and proactive use of P.O.E.T. assessments. Early evaluation indicates improved consistency in follow-up and increased completion of care conferences within 72 hours. While formal satisfaction data collection is ongoing, preliminary feedback from residents and families demonstrates improved communication and clearer understanding of care plans. Early implementation contributed to avoiding a recent non-compliance finding from the MOHLTC.
This initiative highlights the importance of structured processes, defined accountability, and early engagement of residents and families in supporting safe and person-centered care transitions.
Author(s) Credentials and Title
Sarah Love, RN (BScN), ADOC, St. Peter’s Residence at Chedoke – Thrive Group
What RNAO BPG or tool/toolkit is your abstract related to?
Transitions in Care and Services
| Organization Name | St. Peter’s Residence at Chedoke |
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