Spinal Cord Rehabilitation Program – Lyndhurst Centre

Understanding Patient Needs in the Transition
from Inpatient SCI Rehabilitation to the
Community: A Multi-Faceted Needs
Assessment
Sandra Mills
Patient and Family Educator
UHN TR Spinal Cord Rehab Program
HCEA Conference
Education on the Fast Track: Transforming the Patient
Experience
October 15-17, 2015
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Agenda
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Objectives
UHN – SCI Rehab Program overview
Partners in Care
Needs Assessment & Results
Program Opportunity
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Objective
• Describe processes and mechanisms
used to fully understand the lived
experiences of patients with spinal cord
injury in their transition from inpatient to
the community.
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UHN Spinal Cord Rehabilitation
Program – Lyndhurst Centre
May 5, 2015
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Spinal Cord Injury in Canada
The most common causes of SCI
• Traumatic SCI
• Non-Traumatic
The changing demographics
• Increasing non-traumatic
• Increasing co-morbidities
• Increasing females
• Aging
Spinal Cord Rehab Program
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Lyndhurst Lodge- WWII Veterans’ Legacy
Largest Spinal Cord Rehab Program in Canada
3rd largest in North America
On-site partnership with SCI Ontario
In 2014/15 :
• 60 beds - 323 inpatients
• Average LOS 57.1 days
• 87% of patients discharged home
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Our Inter-Professional Team
• Medicine (Physiatrist & Family Physician)
• Nursing (RN, RPN)
• Health Professions (PT, OT, SW, SLP,
Rec Therapy, RT, Psychology, Spiritual
Care, Pharmacy, Neuropsychology,
Rehab Engineer, Dietician)
• Leadership (APNE, APL, PFE, PIL)
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Spinal Cord Outpatient Services
Bone Density Clinic - DXA Lab
Therapeutic Recreation
Gynecology Clinic
Occupational Therapy
Nursing Follow-Up Clinic
Physiatry
Physiotherapy
Psychology
Robson Urology Clinic
Skin and Wound Clinic
Intrathecal Baclofen / Spasticity Clinic
Respiratory Therapy
Hydrotherapy
Assistive Technology Service
Social Work
Speech Language Pathology
Seating Clinic
Nutrition
19,546
Visits 8
Partners in Care is About…
Creating compassionate, caring and
collaborative work environments for staff
Engaging patients as advisors in important
planning and decision making activities
Expanding on existing ‘pockets of
excellence’ and make them leading
practice across UHN
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Patient Partners Program
Engage patients and their caregivers as partners/
advisors on specific high-impact priorities across UHN
UHN’s Patient Engagement Strategy
• Build a Community of Patient Partners who are recruited
and prepared to work with us
• Work together with patients on specific projects, goals and
activities to enhance and improve care at UHN
• Consider & incorporate input and feedback from patients to
make changes/improvements to care
• Support patients & staff in this important partnership
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Introduction
The transition from inpatient rehabilitation to the
community following spinal cord injury (SCI) is a
critical time. Individual’s perceived readiness
for discharge varies, but are there common
elements that can be set in place to assist the
individual, their family and caregivers in this
transition?
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Strategies Used in Needs Assessment:
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NRC Picker In-Patient Satisfaction Surveys – Quarterly surveys
used to identify patient needs across domains related to transition
processes.
Patient Engagement Research Study – Findings were used from
Care Transitions Measure Survey and interviews with outpatients
recently discharged. Interview questions explored patients’
experiences with transition points providing recommendations for
process improvements.
Outpatient Interviews Phase 1 - Face-to-face and phone interviews –
focusing on services accessed, wait times, community supports,
information shared, skills/resources needed and available at discharge,
nursing follow-up phone calls and overall rating of the discharge
process.
Outpatient Surveys and Interviews Phase 2– Face to face interviews
focusing on skills and community resources required at discharge to
facilitate a smooth transition into the community.
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Results
NRC Picker In-Patient Satisfaction Surveys
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Patient Engagement Study: Care Transitions
Measure Survey and Patient interviews:
Dec 2013-May 2014 (n=46)
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Patient Interviews Phase 1
Nov-Dec 2014 (n = 21)
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Outpatient Surveys and Interviews
Phase 2
Feb-Mar 2015 (n=12)
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Key Themes Identified
• 79 people with SCI involved with these key themes emerging:
– Isolation was common in the early weeks following inpatient
discharge
– Medication management required further clarification and
details
– Family meetings and weekend passes prior to discharge
were very beneficial
– Transfer of information between inpatient team and others
(outpatient & community) needs improvement
– Written information in plain language in addition to verbal
education enhanced problem solving in the community
– Spinal Cord Injury Ontario Regional Service Coordination
and Peer Support was of high value
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Common Themes
• Common transition themes exist for
people transitioning from inpatient
rehabilitation to community. A patientoriented discharge summary
considering medication management,
follow-up appointments, and community
supports can assist in this transition.
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Patient Oriented
Discharge
Summary (PODS)
http://pods-toolkit.uhnopenlab.ca/
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Next Steps
Add these two process steps:
1. Personalized, written Patient- Oriented
Discharge Summary (PODS) document
provided for 100% of inpatients by discharge.
2. PODS meeting to occur for 100% of inpatients
one week before discharge.
+ 2 Patient Advisors on the Working Group!
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MASTER TEMPLATE’s Discharge Summary
I came to Lyndhurst and am leaving . I had my meeting with .
I came in because I have inc/ complete quadri/paraplegia or other. I am going to my (home/
condo/ apartment/ retirement home/ hospital) when I leave.
This summary is my interpretation of my plan for discharge. For profession-specific
recommendations please refer to the appropriate professional documentation.
Medications I need to take
Medications will be reviewed several days before leaving by Pharmacist or Doctor. You need a
Family Doctor appointment immediately after leaving to renew prescriptions in time for refills.
Bladder supply list (GU prescription) has (not yet) been reviewed with Nurse or Doctor. You
need to choose a vendor and arrange delivery or pickup of your supplies.
Care Plan
Issue
Plan
Swallowing/
Breathing
Skin
Bladder
Bowel
Pain
Thinking/Memory
Dressing/ Bathing/
Grooming
Transfers/ Mobility
Equipment
Housing
Eating
Cooking/ Shopping
Leisure
Transportation
Coping/ Relationships
Signs and Symptoms and What to do
What if I…
What to do
Feel dysreflexic
Have more mucous, difficulty
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Pre-PODS N=12
Results
5
4
strongly agree
agree
3
neutral
disagree
2
strongly disagree
1
0
Purpose and use of
medications
sign and symptoms
what to do at home
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Post-PODS N=15
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12
10
strongly agree
8
agree
6
neutral
disagree
4
strongly disagree
2
0
Purpose and
use of
medications
sign and
symptoms
what to do at D/C confidence PODS useful?
home
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Lessons Learned
• Be invested in really listening to patient
and family needs, ideas, suggestions
• It takes an army….
• Change is a process, change takes
time, change can have an impact
• Patient advisors are crucial
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Key Take Away Points
• Patient Engagement
• Understanding from the patient voice
• Clinical change based on identified
need
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Thank you!
Sandra Mills
[email protected]
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