Saint Elizabeth plays key role in supporting Hospital to Home transitions through ‘bundled care’

September 03, 2015

A new integrated model of care that helps patients transition more smoothly out of hospital and into their homes is being expanded across Ontario. Saint Elizabeth is excited to be involved in three of only six projects that have been selected to implement ‘bundled care’. The initiative was announced by Dr. Eric Hoskins, minister of health and long-term care, in early September.

Evidence suggests that an integrated approach can result in a dramatic reduction in readmissions, visits to the emergency department, in-hospital recovery time, and – most importantly – improved patient outcomes and satisfaction. The model is based on a successful pilot at St. Joseph’s Healthcare in Hamilton that is improving care and cutting costs. Saint Elizabeth has been involved in this project as the rehab partner/provider for St. Joe’s Home Care.

Here’s a look at two of the other projects that are moving forward:

Putting Patients at the Heart: A Seamless Journey for Cardiac Surgery Patients in Mississauga Halton Trillium Health Partners will work with Saint Elizabeth Health Care to allow patients to go home on average three days sooner after cardiac surgery. This will be supported by continuing specialist engagement and providing care in the home for up to 30 days post-discharge. Key features include an integrated care coordinator that works with patients beginning at pre-op, a 24/7 contact centre and telemonitoring in the home. Project Partners: Trillium Health Partners and Saint Elizabeth Health Care with support from the Mississauga Halton LHIN

Integrating Specialized and Primary Care: The North York Central Collaborative This project is focused on caring for patients with chronic obstructive pulmonary disease and congestive heart failure in the mid- to late-stage of their disease as they transition from hospital to home for up to 18 weeks post-discharge. Patients will experience a collaborative and coordinated team approach across health care partners (hospital - both acute and outpatient, community, primary care). -Project Partners: North York Integrated Care Collaborative (North York General Hospital, Central CCAC, Saint Elizabeth Health Care, Pro Resp Home Oxygen & Respiratory Care, Circle of Care, North York Family Health Team), West Park Healthcare Centre, Central LHIN

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