The City of Lakes FHT is working with Health Sciences North (HSN) senior management and other community partners on an Expanded Care Transition initiative.
The Committee is chaired by HSN CEO, Denis Roy. Its purpose is similar to the Provincial HealthLinks program in which a network of community partners work collaboratively to target the top 5% of patients accessing the health care system with a view of reducing usage and subsequent health care costs. The Care Transition strategy will target 500 complex care patients across Greater Sudbury.
The priority is to improve the hospital discharge process so that patients who are discharged from the hospital do not become re-admitted as a result inadequate follow up or coordination. Discharge planning involves the development of an individualized discharge plan for patients prior to leaving the hospital to ensure that they are discharged at an appropriate time and with an adequate provision of post-discharge services.
The COLFHT established a hospital discharge program in 2012 and will link this program to the efforts of the hospital and the CCAC to better coordinate discharge processes, such as the Rapid Response program, through a collaborative partnership. For example, a post discharge phone call to the patient within 24 hours will improve the transition of patients to the community by focusing on education, instructions and medication management in a timely manner.
Future initiatives include improving the system of automated notifications to primary care providers for admissions and emergency room visits. Also, it will consider the development of a standardized post discharge Meds check in order to provide up-to-date medication reconciliation.
The COLFHT is represented by Lead Physician, Dr. Tom Crichton and Executives Director, David Courtemanche.