Transforming Ontario's Health Care System Care Stories

Navigating the Way to Improved Patient Care - North York General Hospital

"The stay in hospital is just a small point in time in a patient's journey. To ensure the best possible care, we have to get involved before patients arrive and stay connected after they leave," explained Larissa Clemente, who provides patient navigation support at North York General Hospital's (NYGH) hip and knee replacement surgical program. "We have to think beyond the hospital."

Clemente is a clinical nurse specialist and supports the hospital's efforts to bridge gaps and provide smooth transitions in care to create a seamless patient journey from start to finish. Clemente sometimes begins communicating with patients up to nine months before their scheduled date for surgery.

"For patients with mobility issues, diabetes, or who live alone, I discuss how they will cope after being discharged from hospital and put a plan in place before they even arrive for surgery," she said. "I may refer patients to a Community Care Access Centre for a pre-op visit to look at what equipment might be needed in the home after surgery."

Supporting patient navigation is a key component of NYGH's Hip and Knee Integrated Care Collaborative (ICC) – a new holistic model of care that weaves together quality improvement steps to improve patient outcomes and deliver better value.

Health System Funding Reform helped the hospital look for innovative ways to provide patient-centred care more efficiently, support better care co-ordination for patients with complex health conditions and improve access to services and quicker discharge, explained Dr. Tim Rutledge, NYGH's president and Chief Executive Officer.

"The hip and knee ICC aligns with the goals of Health System Funding Reform by improving outcomes for patients, while delivering value by containing costs through better ways to deliver health care," Rutledge said.

To implement the Hip and Knee ICC, NYGH looked at elements already in place, considered the gaps and decided what needed to be done to evolve a more integrated way of caring for patients.

Some of the improvements already in place included :

  • The Total Joint Assessment Centre – the brainchild of NYGH's orthopaedic team – is a centralized, streamlined centre where patients receive an appointment within three weeks of referral and are assessed by an orthopedic nurse or physiotherapist to determine whether surgery is the appropriate option. The centre has freed up more time for surgeons to see patients who require surgery and has resulted in operations scheduled in about three to four months' time, instead of historical wait times of up to a year or more.
  • A general practitioner – or hospitalist – for the orthopedic floor supports patients with medical issues unrelated to their hip or knee surgery. The hospitalist does daily rounds of all hip and knee in-patients and responds to any medical issues that might delay their discharge once they have recovered from surgery. This ensures a hip or knee replacement patient doesn't stay in hospital longer because their asthma or diabetes isn't well controlled.

Patient navigation support links all the steps taken to improve the patient journey, noted Linda Jussaume, Director of Surgical Programs.

"Patient navigation involves intervening and supporting patients at any stage," Jussaume said. "We can red flag patients pre-op. We can work on issues like weight loss and physiotherapy before surgery," she said. "We're looking to technology like Skype so a patient can show Larissa their wound from home."

Connecting all stages and aspects of patient care has been essential to the ICC's success. "We've become more integrated. We're working together from all these different perspectives to optimize patient care and increase positive results, such as getting patients mobile and discharged sooner," said orthopedic surgeon Dr. Hossein Mehdian. "Enhancing patient navigation makes the whole process more fluid and makes the connections easier for patients."

This was certainly the case for Mary Thomas who was concerned about her painful and swollen knee a few days after she returned home following surgery. "I called Larissa. She was able to contact my surgeon's office and get me in quickly," Thomas said. "It was really helpful to have one person to call."

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