From Hospital to Home

They say that home is where the heart is, but supporting patients to transition home or into the community is a challenge that many Canadian healthcare organizations grapple with. Making these transitions as seamless as possible is crucial to patient and family experience as well as health outcomes such as hospital readmissions.

Through the EXTRA: Executive Training Program’s cohort 12, a collaboration and improvement project (IP) was born between three organizations in Kingston, Ontario, to address transitions in care for patients no longer receiving active therapy.

Jenn Goodwin, Senior Director, Community Relations & Strategy at Providence Care and one-quarter of the Kingston team sat down with CFHI to discuss their process and journey.


Kingston team photo



A seamless transition

The Kingston team is drawn from three organizations: Providence Care, Kingston General Hospital (KGH) and South East Community Care Access Centre (South East CCAC).

The team’s IP focuses on the transition that occurs for patients when they are no longer receiving active therapy – such as chemotherapy – from the Cancer Centre, often because they are no longer well enough to leave their homes and go to the clinic.

“During this transition, their care stops being provided by the hospital-based Cancer Centre team, and is led by either their family or a community-based palliative care physician,” Goodwin explained.

Each patient is different, and providers must do their best to respond to the unique needs of each individual – which isn’t as easy as it sounds.

“This can mean that there is confusion about what resources and what providers are involved, and a lack of consistency in the resources made available.”

Goodwin believes that their IP will bring more clarity to the process – and to some extent, standardization.

Part of that means striving to make the transition from being an outpatient at the Cancer Centre to receiving home-based palliative care feel as smooth as possible, almost to the point of masking the feeling of a transition.

“At the same time, we recognize there is a hand-off between care teams. To this end, our IP looks at drivers that include what information is available to the patient, family and care staff.”

The IP examines how patients can access that information, what resources are consistent across the organizations, and the timing of when these supports are made available.

The Kingston team’s IP is working to establish a centralized point of intake for patients who are referred for palliative services, regardless of the care environment or care providers.

The centralized intake will support referrals made by a patient or patient advocate, primary care provider or specialist provider.

Team Dynamics

The Kingston team is unique in that each of the four members are from different organizations. Comprised of a VP, Cancer Services and Diagnostic Imaging, a Senior Manager, Client Services, a Palliative Physician and Goodwin, each member has different skills, experience and strengths. It hasn’t been a challenge though, according to Goodwin.

“We’ve come together so quickly and work well together. We have a strong commitment to patient care and a shared desire to make change that impacts the people we serve.”

Part of that commitment comes from the fact that each team member has had experience with family members or friends who have received palliative care, which for Goodwin is explains why the team is passionate about this topic.

The EXTRA approach

The Kingston team applied to the EXTRA program because it offered a grounding in quality improvement methodologies and their leadership teams saw value in the structure of the program over an 14-month period.

“Recognizing that quality improvement is ongoing, we are approaching this as an opportunity to learn about it and to practice it, but also to transfer our knowledge and learnings to others within our organization.”

EXTRA provided an opportunity for Goodwin and her team to build and grow local communities of practice.

“We are also now seeing the incredible value in networking across the country – we have so much to learn from each other.”

The hands-on approach of EXTRA has reminded the team that they can only go one step at a time and need to engage with the staff in their organizations and family physicians in Kingston to really be successful.

“By being hands-on in this project though, we have a real appreciation for the attention to detail and different skillsets required. We’ll be able to spread and support the use of quality improvement methodologies within our organizations more effectively from the EXTRA experience.”

Currently the team is in early rounds of the Plan Do Study Act model, which is a fundamental tool in quality improvement work.

“We have three or four small change ideas that we’re implementing, and we’re working with teams of frontline staff and patient partners to see if these ideas are feasible and worthwhile.”

Patient advisors are playing a major role in the IP at every step of the way, according to Goodwin.

“Even in the application phase, our conversations were led by people who had received the services and could provide a clear picture of what their experience was like.”

As the IP evolved, it went on to include a different patient and family representative in each working group including an individual who went through the transition with his partner just in the past year.

Goodwin has been able to share her experience as an EXTRA fellow with her senior leadership team and colleagues who are quickly seeing the value and showing interest as well.

“Those who have some knowledge of quality improvement are excited to see Providence Care, KGH and the South East CCAC come together and take such an interest in supporting this project.”

On a personal note, Goodwin is both honoured and grateful to be a part of this work.

“I’m excited by the potential that our team is helping support meaningful change.”