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Ministry Reports

Enhancing the Continuum of Care
- Dr. G. Ross Baker

November 15, 2011

In September 2010, the ministry convened an Avoidable Hospitalization (AH) Advisory Panel and named Dr. G. Ross Baker as the chair. The Panel had a mandate to identify :

• system-wide AH best practice guidance,
• form and content of an AH improvement practices inventory, and
• measures and an evaluation framework for AH initiatives

Dr. Baker and his Panel have completed their work and submitted their report, Enhancing the Continuum of Care, to the ministry.
The ministry would like to thank Dr. Baker and Panel members for their work over the past year and their thoughtful advice and recommendations in this important area.

The ministry is reviewing Dr. Baker’s report.

Steps have already been taken at a provincial and local level to implement initiatives in line with some of the recommendations found in the report. Specifically :

Innovative models of care: Some promising practices and interventions developed through partnerships between different health care providers aimed at improving the continuity of care are being piloted in Ontario. Key among these :

• Virtual Ward – is an innovative partnership between Toronto area hospitals and CCAC that assesses patients risk of readmission to hospital (using the LACE Index) and ‘admits’ them to the Virtual Ward on the day of hospital discharge. They receive care at home from an interdisciplinary team that provides CCAC case management and hospitalist medical support, integrating post-acute primary and home care. The Virtual Ward team shares a common set of notes, meets daily and has 24/7 physician availability.
• LACE Index: Readmission Prediction Tool used in many hospitals in Ontario predicts the risk of death or unplanned readmission of cognitively intact medical or surgical patients after discharge from the hospital to the community. Key factors associated with these events are length of stay (L), acuity of admission (A), patient comorbidity (C) and number of visits to the emergency room (E). Depending on a patient’s LACE score, enhanced services focused on improving transitions of care, including post acute care support, are arranged accordingly.
• South West LHIN Transitions in Care Initiative focuses on the role of a Care Transition Coach who visits at risk patients prior to hospital discharge and again following their return home. The Care Transition Coach is a nurse practitioner who provides patient education, ensures that follow up appointments are made and reconciles the patient’s medication at home. The program aims to enhance patient outcomes, reduce adverse events and, particularly, to reduce readmissions

The full report may be downloaded from the link below.

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Enhancing the Continuum of Care - Report of the Avoidable Hospitalization Advisory Panel
48 pages | 643 kb | PDF format

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