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Optimizing Transitions of Care - Hospital to Community
Emily Sheridan1, Christine Thompson2, Tania Pinheiro3
1Started her career on the Acute Medicine Unit at St. Thomas Elgin General Hospital (STEGH) as a staff nurse. In 2014, she moved into the role of clinical educator, working out of the Transforming Care Office, specializing in LEAN. She has received the Lean Six Sigma Yellow and Green Belts, and completed the IDEAS Advanced Learning Program (where the Optimizing Transitions of Care project was born). Since 2015, she has worked as a staff nurse in the Emergency Department, while still working on the Optimizing Transitions of Care project in her spare time.
Abstract:
Discharging patients from the hospital is a complex process, and preventing avoidable readmissions has the potential to improve both the quality of life for patients and the financial sustainability of the healthcare system (Alper et al. 2016). Improving the discharge process is one method to mitigate readmission to the hospital. Historically, St. Thomas Elgin General Hospital (STEGH) consistently experienced higher-than-expected readmission rates, and only 41% of discharge summaries were sent from the hospital to the community primary care within 48 hours. In addition, the overall percentage of patients attending a follow-up appointment with a primary care physician within seven days of discharge from hospital was lower than the provincial average. Through engagement with primary care providers (PCPs) and clinical associates (CAs) and with the use of standard work and monitoring organizational metrics, STEGH has achieved significant improvements.
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