Speaker
Description
Background Rational
Our team began implementing Transitions, at which time we identified a number of gaps within multiple areas related to transitions in care. As a team we worked together to review our admission process, hospital transfers and external appointments to determine where specific gaps were presented.
Our goal was to collaborate with our residents/families to develop tools to support and improve communication during transitions. Aim was for transitions to be resident focused to support our residents through every transition
What Move in Day looks like. Once a bed match confirmed by Ontario Health at Home, team members reaches out to the resident and/or POA to invite them for a personalized tour, meet and greet with the team. On this tour they receive admission package to review, to provide an opportunity to minimize the paperwork on actual move in day. In addition, a welcome email is sent, detailing a list of documents and items required for admission. Tools that have been developed to support this process and guide in better getting to know our residents will be shared here.
ER transfer- As a team, we make every effort to utilize in house resources, such as our NP, to reduce ER transfers, however when it is deemed necessary. Developed and implemented ER transfer note as well as checklist of what to send with resident to ER to ensure communication is detailed and thorough.
External Appointments – Created a checklist to enhance and ensure accurate communication for all external appointments.
Utilized support from our Regional team for policy review, to ensure legislative compliance and to support implementation planning.
Results
Complaints and concerns following a transition have decreased.
Lessons Learned
sustainability must be considered when brainstorming change ideas
Education and update always takes longer than anticipated--- clearly communicating the vision are challenging
Author(s) Credentials and Title
Jodi Hanson RPN Clinical Lead, BPSO Lead
What RNAO BPG or tool/toolkit is your abstract related to?
Transitions in Care and Services.
| Organization Name | Westhills Care Centre |
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