Nursing Plan Of Care

♪♪♪ (patti cochrane) hello. welcome to "talk trillium: partnering for patients." my name is patti cochrane, senior vice president, clinical strategy, and chief innovation officer at trillium health partners. we have three sites, the credit valley hospital, the mississauga hospital, and the queensway health centre. i'll be your host today as we talk about

how trillium is partnering to create a new kind of healthcare for a healthier community. and today's episode is really around transitions of care. and it's my great, great pleasure to welcome dr. walter wodchis. he is an associate professor at the university of toronto. he's also the principal investigator for health system performance research network at the university of toronto.

so, welcome, walter. (walter wodchis) well, thank you very much for having me. it's such a pleasure. (patti cochrane) oh, and we are thrilled to have you here. so, what is your role? after that great introduction and lots of words, tell me what you do. (walter wodchis) okay, so i have a couple of roles. but a lot of the research, which i think we're going

to talk about today, i lead two research programs. one is funded by the ontario ministry of health, and it really is about understanding the population of ontario, how they use health services, and particularly, those people who have very complex needs over a long span of time, repeatedly, needs that don't go away. and i have another program that's funded by the canadian institutes for health research,

our federal research agency, and that one is really understanding how do we implement the best programs, especially for older adults who have multiple complex health needs. (patti cochrane) now, you're becoming very famous for some of the research findings that you've had. and one of the quotes i'll use, because i know that we talk about it in our own organization,

and i know many organizations talk about it, and the really startling discovery that just 5% of our population consumes 60% of our healthcare resources. can you talk a little bit more about that? and what does it really mean? (walter wodchis) sure. so the first thing it means is that 95% or 99% of us are quite healthy.

(patti cochrane) that's good to know. (walter wodchis) that's good to know, right? and so most of us don't really need a lot of health care. that's the first thing. then among those people who do need lots of care, how well are we delivering it? for some of those people it's over a short episode of care. and we'll talk a little more about this, i hope, today. and for many, though, it's also care that must continue

over multiple years because they have many conditions that don't go away. and their needs are such that they need both medical care as well as, often, community and social services, and home care services. (patti cochrane) so it seems to me if we focused on the 5% of patients who do consume large-- have lots of healthcare needs, we might be able to think of ways of improving their experience with the healthcare system.

(walter wodchis) yeah, so when we have looked at the data, and we see the kinds of patterns of care these people have, we think there are some opportunities to improve their care. we see people who have multiple readmissions to hospital. they're discharged home. people aren't able to see their own family physicians within a timely manner. you know, they say, "see your doctor when you get home."

but it could be weeks or months before they do. and those people end up being readmitted back to acute care. opportunities to better improve those transitions, i think, is really one of the biggest opportunities. and then just people who have 5 and 6 different specialists, maybe have 17 or 20 different medications, a lot of times it's very difficult for them to coordinate and prioritize among their many conditions. and there, too, better coordination

and care management for these people over the long term really should be able to keep them where they want to be, in their homes, and not visiting hospitals. (patti cochrane) so, on the next segment of this show, right after the break, we will be talking a bit more around bundled care. and i know that there are six that were awarded in the province. can you speak to me about your role in that work?

and what do you think we'll expect to see? (walter wodchis) okay, well, so we do, at the university of toronto, and with our network of researchers, a lot of evaluation. and so we've been asked by the ministry to evaluate the implementation of these six programs. and there are quite different programs. trillium has one in cardiac care. but people are looking after people with heart failure,

with stroke, with chronic obstructive pulmonary disease, so, many different conditions. to understand that transition, the acute care, but then also the care in the community. and they're calling it a "bundle" when they put that care together. we're interested in understanding how organizations that haven't worked together before are really collaborating in their care and putting these pathways together

that did not exist before from hospital to home. how did they do that? and what makes it more successful, in being able to do that? and we are interested in understanding, does it help people not to be readmitted back to the hospital, and to use less hospital care? and what is their experience like? do they feel that their care is well-coordinated?

and so we'll be following people in the data, as well as doing through interviews and surveys, to really understand this organization patient perspective. and it's also, we think, going to have some impact on caregivers who often, when people go home, must be the people taking care of them. (patti cochrane) so patients and families, i know that our ministry of health are really focusing on what do the patients want

in their healthcare experience, as well as their family members, which you just indicated. it seems like we're moving more towards really understanding what do patients want, and how can we help them stay healthy at home, because nobody wants to come into hospital, really. so in terms of where you're viewing the system going, how are we going to incorporate the voice of the patients into how we develop models of care?

(walter wodchis) so i think through patient engagement and using patients to help design the care that they will receive. so having them in the room when the pathways are being designed to say, you know, "you can't tell me that on the second day "i need to go see my doctor, because i'm not going to be "able to move unless there's some transportation to help me get there."

or can we have, for people who are frail in the community, and homebound, what kind of options are there for having physicians visit them at home? so this is talking to the patients and really understanding what their challenges are and bringing them into the conversation. and that's, i think, many organizations are doing that so much more. not just a patient on an advisory council,

but involving them in the design of care. (patti cochrane) and so you talk about the design of care. it must be that we are designing for the future in a different way. we talked about bundled care. but can we kind of take a glimpse into the future, and what other types of solutions do you see for these high users of patients in the system that really have to interact

with our healthcare system so often? (walter wodchis) oh, so many different things are going to happen. care will very much be more oriented in the community. and then it's how do we do that effectively? sometimes it's bringing care providers to the people. but often i really think that we're starting to see telemedicine. we're starting to see physicians visit patients, very few of them right now, but visit patients

via the internet in the patients' own homes. and i think we're going to see so much more of that, as well as patients checking in on their own health records from their homes. and we will want more community programs to keep people moving about, not just staying in their homes. we need people to be active as much as possible. but i think that the notion that all care is delivered

in the hospital is not going to happen. hospitals are going to be there. people need very intensive care at points in time. but the orientation of being the only place where you get care, very much going to change. (patti cochrane) so it almost seems like there's going to be a vision of hospital in the home. and that really means your doctor coming to you via technology, and being able

to stay healthy and well using technology into the future. (walter wodchis) yeah, and nurses will visit you in your home. it's not going to be completely digitized. we still have people. (patti cochrane) wonderful, 'cause that's so important, hands-on care. but it sounds like a combination of both as an opportunity for the future. (walter wodchis) i see that being a really--

that being one of the most significant changes. and i think care all being organized around communities and local areas will also be much more the case. (patti cochrane) so if i were someone in the community with one of those chronic conditions that require a lot of, you know, going to see my family doctor and going to see the hospital a lot, do you have any advice for me as an individual on how i can be healthier at home?

(walter wodchis) so i think the first thing is to-- do you understand your care? do you understand what you're supposed to do? do you understand how food affects your health? do you understand what your medications are for? if you have any questions about these things, you really need to bring those up with your care providers, with your nurses, and with your primary care physician, with your home doctor.

that person can really help you understand those. and then what can you do? and nurses are excellent at coaching people to what they can do to be more active, to take better care of themselves, and orient that around their own goals. so i think bringing yourself and your own goals into the conversation and say, "this is what really is important to me.

how can we help me get there?" (patti cochrane) yeah, so being very involved in your own health is important. and speaking of being very active, how do you maintain your own personal health, walter? (walter wodchis) so i just stay active. i ride my bike to work. i walk my children to school. i rarely use my car. i use it if the trip is more than 10 kilometres or i have a really big load to carry. but i walk. i just build it in.

i don't--i'm not very good at going to the gym, actually. i do swim sometimes. but i just have to build it into my daily routine. i walk to buy my groceries. and i think that the more people are able to do that and keep that active living, the healthier we'll all be. (patti cochrane) that's great words of advice. so thank you so much for joining our show today. stay tuned to "talk trillium" and our next, after the break,

we'll be talking about our bundled care experience. thank you. (patti cochrane) welcome back to "talk trillium." in this segment of our program, we have saint elizabeth, who's come to us as a partnership with trillium health partners on delivering bundled care, which we heard about in our previous segment. so i'd like to introduce our guests today, rheta fanizza. she is the president of saint eliz.

elena holt, welcome back to "talk trillium. she is the program director for cardiac health helene lacroix is the vice president at saint eliz. and chandra persaud-bacchus, she is our nurse practitioner in our cardiac program. so, welcome all of you. we've all gotten to know each other, haven't we, over the last few months.

so, rheta, talk to us a little bit about saint eliz. who are you? (rheta fanizza) sure, so we are a national non-profit social enterprise, and we work across the country in a variety of settings. i think we're best known for our work in home care. and we've been doing home care for over 100 years. (patti cochrane) wow, 100 years. (rheta fanizza) yeah, 100 years plus in the province of ontario. we also have various partnerships and services

that we provide to hospitals, to long-term care, to physician practices, throughout the country, and first nations as well. (patti cochrane) so how many employees would you have at saint eliz? (rheta fanizza) we have a bit over 8,000 now across the country. (patti cochrane) wow. (rheta fanizza) yeah, so we're growing every day. and i'm very pleased to be in the partnership with trillium health partners.

i think this is such an innovative program, and really something that's wonderful for patient care. (patti cochrane) and so what was the incentive to partner with trillium health partners? you clearly do work with many organizations, but this is a little bit special, i think. (rheta fanizza) more than a little bit special. really, i think it's just a wonderful program that we're embarking upon.

and trillium health partners has been an organization that we've worked with in the past. perhaps not as closely as we are now, but really have great similarities in terms of our values. you know, trillium health partners certainly is committed to excellence to person and family-centered care. and i think, also, you know, in the spirit of innovation, you know, that whole piece about changing

and doing things differently. and we share those values very deeply, and are just really excited to be part of it. (patti cochrane) well, thank you. and elena, how did the cardiac program get chosen for this bundled care experience, which is really around improving transitions from hospital to home for patients? (elena holt) well, specifically, in the cardiac program,

it's cardiac surgery. so patients really go-- can often very quickly go through being well at home, and then suddenly having chest pain and coming into hospital and then needing cardiac surgery and having that done and being sent home all within a week or two. and that's a great deal to adjust to.

and the cardiac surgeons and the cardiac team thought it would be an awesome opportunity to partner so that the families and the patients can feel like it's not so scary. 'cause it can be, you know, from what they perceived as healthy to, "i just had cardiac surgery. what does that mean for my everyday life?" to being at home and feeling alone and isolated. and that's where this partnership is really beneficial

for the patients. (patti cochrane) excellent. now, helene and chandra, you're very close to the patient care. and can you describe how you started to work together in a new way and to create a new model of care for patients after cardiac surgery at trillium? (helene lacroix) well, it really started about, almost a year, a little bit more than a year ago,

when we came together as a collective team to really look at how we could improve things for patients and families. so what kinds of-- how can we organize services in a way that would benefit patients and families after-- or during, throughout their experience of cardiac surgery better than what they experience now? and we had a patient as a member of that initial team

to help us establish that vision and define those opportunities. and from that, we started putting together teams that would help us really figure out what that care might look like. (chandra persaud-bacchus) you know, we really did use patients a lot when we developed the bundled care model. we looked at what patients were telling us at the bedside. we're lucky in cardiac surgery that we have a number of very seasoned clinicians,

from nurse practitioners to the surgeons, who have been there from the initiation of the program in the year 2000. so we've been in--the program has been in progress now for 2000, or since 2000, the year 2000, for 15 years. so having the experience of the clinicians, as well as the patients who, their testimonial at the bedside, and the patient care surveys.

and we had some volunteers who had also had surgery at our institution and were happy to provide us with feedback. so based on that information, we used their experience to develop the bundled care program. and we looked at, you know, what were the shortcoming of the program. and we built the model around that. so looking at having a coordinator

within the program who's linked with the patients and who helps them organize some of the community services. and then the 24/7 callback line, which we established to help patients and families, support them in the community. and the other, through saint elizabeth, some of the initiatives, having the nurses go in early so that they're able to symptom management patient or follow up on any concerns that they have.

some of it will be virtual care through saint elizabeth's services. so there's a lot of initiatives that we built based on what we saw were opportunities to improve the transition of care from patients to home. (patti cochrane) and so, helene, can you explain to us, what is the difference in this experience for patients after cardiac surgery as a direct relationship in the planning and the design of the program?

(helene lacroix) i think that the biggest, the most substantive difference is really that focus on seamless transitions of care. and those words have almost sort of become to be a bit of buzzwords that perhaps don't mean as much. but i think within the context of our group it does mean something. and what it means is that patients can expect care from staff in a community who, because of the direct connection to staff in the hospital,

have a clear understanding of what their experience during hospitalization was, how their recovery from surgery has gone up until now, and can use that information, as well as knowledge that they've gained through joint education that we've done with trillium and the staff on this post-op surgery unit, to expect that they get, you know, good continuation of care based on knowledge of what happened to them before.

and from the same approach and perspective as they got in the hospital. so, truly continuous care once they go home. (elena holt) and they get that knowledge through a shared document. so this is very new to have the document that's in the hospital shared within the community. and both sides can input into that same document so that it's very current knowledge for that patient and it's very seamless.

(helene lacroix) plan of care, right? (chandra persaud-bacchus) and we don't use the word "discharge" now. we talk about transition because we like to see it as one episode of care where patients are actually, it's a seamless transition. whether they're coming from, you know, when they come from the community or another hospital within our hospital and then go home, it's all one episode of care.

it's one chart. we all have access to the information, as elena was saying. and you know, so, and we have, like, one team, like the trillium and saint elizabeth is one team, 'cause we've done a lot of cross training so the hospital team understand what services are offered in the community and vice-versa. (patti cochrane) so it sounds like you're integrating the teams.

(rheta fanizza) yeah, absolutely. and just one other point to add. we're very excited about the opportunity to have some patients also be supported by technology. and so there's going to be remote monitoring. and so patients, we can check in on them without actually having to pay a visit to them and see, you know, how they're doing, check their vital signs, and get feedback from them,

and have it monitored through a nursing group at saint elizabeth, so. (patti cochrane) that's an important factor, i think. so we're applying some technology, but we're still keeping the human touch in visiting patients, and both. and, elena, your point around the integrated record so that everybody understands what's happening is such an important tool to use for care.

now, does the patient have access to that tool? and how does the patient get involved in their care plan? (chandra persaud-bacchus) so we developed this integrated care record with the patients, the multidisciplinary team in hospital, and that record is uploaded into our communication system which we share. and the patient goes home with that record. so the patient and family, the team and the community, and the hospital team all understand what's important

to that patient in their recovery. we all follow that plan of care that was made up with both teams and the patient and family. (helene lacroix) and at home, our nurses will have access to that record electronically using a tablet. and although at this point in time, patients can't directly access it, that's on our to-do list. we tried to keep it simple, as everybody remembers,

in the beginning. but, absolutely, the patient can sit by the nurse and take a look at their records, can look at trending of vital signs through graphical representations in their health record, and can absolutely participate and view everything that's written down about their healthcare as they progress through that 30 days

after they were discharged from hospital. (patti cochrane) and we know that medication reconciliation is one of the important roles that the nurse can help support a patient through. does anyone want to talk about that, that important step for patients? (chandra persaud-bacchus) medication reconciliation is one of the new aspects of bundled care that we thought was really important. it's having the medications that patient came into hospital

on reconciled in hospital. and that reconciliation process continues in the community. so the saint elizabeth nurse gets a record of all the patient's medications. they go in the home. they look at all the medications that the patients are on in the home. and they make sure that that meshes with what the patient was sent home on in their prescription.

that's an important aspect that we thought was important in terms of preventing readmissions and emergency visits. 'cause we know sometimes that confusion in medications, especially patients that come into hospital and they have multiple co-morbidities and they're on multiple medications, that really, i think, is key to preventing readmissions. (helene lacroix) and if i can just add, one of the really, i think,

i want to call it innovative. it probably shouldn't be. but one of the really great aspects of this project is the capacity, our capability, in the community to connect right back to people like chandra and the hospital once a patient is discharged. 'cause typically what we need to do to finish medication reconciliation in the community is, you know, access the gp, who's, you know, very busy

and who may not yet have received all the information about the patient's admission at that, during that first visit, or to a pharmacist. and so the ability to directly link back to resources in the hospital for us is absolutely invaluable. and i think will result in some terrific outcomes for the patients in terms of real clarity right from the get-go with respect to their medications. (chandra persaud-bacchus) great point.

(patti cochrane) yeah, great point. you mentioned outcomes, helene. and so, from a hospital perspective, what outcomes, elena, do you think we'll be tracking, or do we expect? i think, chandra, you mentioned something about ed visits. are there others? (elena holt) so, certainly, the one that really matters is patient satisfaction and also provider satisfaction. so we'll closely be monitoring both of those.

and we're quite hopeful that it will be positive for both. (patti cochrane) yeah, and i think-- our surgeon believes that our readmission rates, you know, the need for patients to come back to an emergency department or to come back to hospital for admission will go down just based on the better integration of this care. (elena holt) absolutely.

and the opportunity to have their questions answered in a timely way. (patti cochrane) yes, real-time, 24/7, from this telephone line that will be available for them. so that's great. now, rheta, you mentioned saint eliz is right across canada. and i'm just wondering, what other innovative programs are you involved in?

are there other bundled care experiences that you're working with, or other new models? (rheta fanizza) we are involved in testing a few other models. but i must say that the one here at trillium health partners is very much under consideration across the country. we had some meetings with some folks in alberta just last week and were talking about it. they're very excited about learning from this opportunity and seeing how to implement it in a more provincial way.

so i think that there's lots of interest. and it's just starting to really get underway. and, again, i think the project here, with the outcomes that we're tracking, with the process that we've gone through to make sure that patients and caregivers are well supported will get great results. and everybody's going to be wanting to replicate it, so. (patti cochrane) i know that there were so many people

that were very passionate about understanding how to implement this one in particular. but i think probably the most important thing were things that are soft skills, and it's about relationship building and learning each other's roles so that we can better understand both the community care and the hospital care. and hats off to all four of you and the work that you've done

going forward for others to follow. because i expect that there will be other bundled care experiences. any last words of wisdom on something that we've learned though this experience? that's kind of a tough question, perhaps. but i think it was a little bit complicated 'cause we had to think about health records and financing, not just the clinical care path going forward.

but any last words? (rheta fanizza) well, maybe if i could just start. i mean, i think under your leadership it's been terrific because we have spent the time to lay the groundwork well and get clear about whose roles are, you know, who's doing what, making sure that the patient is always at the centre of our work. and i think, you know, as we progress, we'll progress much more quickly

into other populations if that's, you know, possible as part of the future. because we've laid that groundwork really well. (patti cochrane) great. (helene lacroix) i think, if i might add to that, that it's-- i think it's part of the groundwork that you were talking about, rheta, and that's really the trust that i think has developed amongst all of our teams.

i think our staff know each other by name. and, you know, with the education that was done collaboratively and the time that we spent in the hospital and that some of your staff spent in the home with some of our nurses, we've really developed a wonderful trusting relationship that really allows us to have the kind of open and honest conversations and discussions that need to happen

in order to make sure that the best things happen for our patients. and that, to me, has been absolutely incredible. (patti cochrane) and i love that word, "trust," because we expect our patients will be trusting of this process as well. so, really, thank you so much for joining us today on "talk trillium." and good luck in all your future ventures forward. (all) thank you.

(patti cochrane) great. (patti cochrane) welcome back to "talk trillium." this segment we're going to be talking about planning for discharge. i'm really pleased to welcome our guests this morning. michelle draper, you are the director of operations and flow at trillium health partners. dr. seema marwaha, you are an internal medicine physician

at our trillium health partners. ryan gostlow, you are a social worker at trillium. and nadia bertolo, you are also a social worker at trillium health partners, very involved in planning for patients being discharged from hospital. maybe i'll start with you, michelle. what is your role? you're the director of operations and flow, what does that mean?

(michelle draper) well, i think it can mean a couple of things on any given day. i'm really most concerned about how patients are moving through our system. and that could be both internally at all of our sites, or also out to the community as well. we know that when people move more smoothly through the system we actually create better access for everybody

that is waiting for the care that we have. so i look at, on a day-to-day basis, what it's looking like in terms of some of the challenges that we may be having, and trying our best to work with all of our teams to ensure that we can get patients to their beds. and also helping our discharge planning teams, if we have any difficulties around barriers or different things like that, to ensure that we can

actually get people back to their homes in a timely manner. (patti cochrane) and, seema, from a system perspective, oftentimes we may have patients that have to wait to access a bed in the emergency department. we all realize that that's not the best for patients. but equally challenging is ensuring that patients are transitioned safely at the right time

or being discharged from our hospitals. so there's a big role in linking those two together. people often don't understand it. what is the role of physicians at trillium health partners in the whole discharge planning process? 'cause i think you see it from all angles. (seema marwaha) yeah, i think so. i think the challenge is that like we are, as physicians, are a part of a larger team.

and so, you know, we work together with our social workers and our physios and our ots to really start talking about discharge from the very beginning. i think the physician role, specifically, is to treat the acute medical problem that brought the person in in the first place, really navigate them through their hospital stay, sometimes to answer questions about their chronic medical conditions that they may have, and then to be that communication person.

so you see the person on day one. you talk to their family. you let them know, sort of, what you think their stay is going to be like. and then you see them every day. and then you're the person that signs and communicates their discharge summary. so i think really providing that consistent communication role can be really helpful.

and i think that's sort of what our role has evolved to become in addition to the treatment. (patti cochrane) and over to ryan and natalie. seema mentioned, you know, that there's an interdisciplinary team that really plans the discharge that includes social workers but also other allied health. can you talk about who is in the team, and what is your role specifically?

and i'll address it to both of you, but-- (nadia bertolo) do you want me to? (ryan gostlow) sure. (nadia bertolo) so we're all unit based. and each unit has an interdisciplinary team. there's physiotherapists, occupational therapists, the nurses, the pharmacists, dietitians. there's a whole slew of professionals on the team. we meet daily.

we start our assessments early on. as soon as patients are admitted into the hospital, the assessment starts. we're starting to get a sense of what the patients were like in the community, how they were managing there, and assessing what changes may have happened because of the medical condition. so we meet daily. we talk about the progress of the patient on the unit.

and then as the social worker discharge planners for the team, we're meeting with the patients and family regularly to update them on the progress, what we're seeing happening, and the recommendation from the team around what we could be offering for them when they're ready for discharge from the hospital. (ryan gostlow) and as nadia said, we kind of coordinate and facilitate the discharge, especially for people who have complex medical or psychosocial needs,

by taking what the team has said, and by what we've learned from assessing the families, to put together a safe discharge plan for them. so that's, like, providing access to community resources is one of the primary things we do. that's connecting with our community partners, providing education, and advocating on behalf of patients and families who can't for themselves.

but i think two of the really-- the most important things nadia and i do as social workers is providing people with coping strategies and skills, and empowering patients and families. they come to us facing sometimes life-changing or life-limiting illnesses. and often they're terrified about, "what does this mean for the future?" and scared to even leave the hospital.

so what we do is help them see past the fear in order to be able to take the next steps in their journeys. but all the community supports and coping aren't enough if people don't take an active role in their own health and well-being. and so that's where the empowerment piece comes in. we look at a family or a patient and we help them identify the strengths that exist within themselves, and within their

social support networks, and we teach them how they can leverage these things to thrive when they get back into the community. (patti cochrane) and nadia and ryan, i'm sure care has changed over the years. because it used to be that, you know, we used to do surgeries and patients used to stay for 5 days after a gallbladder operation, for instance, and now that's all done as a day procedure. so, you know, the patients that come into hospital today

are much sicker than they were before. what are some of the more-- what are some of the biggest challenges you face in your role in preparing patients to go from hospital to home? (ryan gostlow) a lot of times it really is, i mean, our system is excellent in meeting patient needs, the community and the hospital. but a lot of times there's just not enough to go around for everyone, hospital is great,

but especially when we hit the community partners part. so, often the most challenging thing is really just the advocacy, trying to get the right patient the right resources when they need it. and a lot of times it really means thinking of creative solutions and creative ways of helping people that are kind of outside of the box to help them thrive in the community. (nadia bertolo) we do a lot of work partnering with the community resources.

we really try to establish good relationships with them so that if we're making referrals, there's trust between us. that if we're making a referral for our patients, on a patient's behalf, that agency is able to pick up that referral very quickly. and it just helps with the process for the discharge. but, you know, just getting back to the challenges,

i think patients do come into hospital still with the framework of, "oh, we'll be here for a very long time." so it does help to start the conversation early on that, you know, "we're working together with the physician. "the doctor's doing what they need to do to get you better, "but we're going to work with you starting from day one "so that when the doctor says you're ready to go, "you're ready to go.

"we'll have the services in place. "we'll have everything organized for you so that you feel safe in the discharge." (patti cochrane) and speaking of doctors' roles, seema, maybe i'll ask you to just speak a little bit further. how do you know when a patient is ready for discharge? (seema marwaha) you know, it's a complex thing. i think the hardest part is--

and i think every team member would experience this-- is trying to understand what the person was like prior to them being sick. and i think that you really want to get them there, or as close to there as possible, or on the track to getting there. i think managing expectations is one of the most difficult things that i face on a daily basis, because as you mentioned, you know, people used to come in after,

you know, delivering a baby and stay in the hospital for several days. and that is absolutely not the case anymore. and if people are coming in expecting that, and it's never really addressed till the day they go home, then it can make that process more difficult than it needs to be. so i think you try to get the information as best you can.

i think one of the things we can do a much better job is trying to understand, sort of, what their community care is like, connecting with the community physicians and the community care providers, and sort of seeing what the patient was like prior to them getting sick. i think if you have a good understanding, then you can really sort of make a good a prediction

as to when they can go home. and then it's sort of a team-based decision. so you talk about their rehab needs and their social work needs and things like that and then pick a day. (nadia bertolo) can i add to that, that bringing in the family in that discussion is really important? 'cause they're really the experts on this patient. and particularly in situations where the patient

can't speak for themselves, if they have a dementia, or if they've had a stroke, the family really acts as an advocate for the patient. and we really need to bring them into the whole planning because they're the ones that are going to make the discharge successful. (seema marwaha) yeah, i totally agree. (michelle draper) and i think to even add to that, we need to do a really good job at,

when we're engaging people in the beginning, helping them know, as we expectation set, that, "we think you'll be here for this amount of time," so that people can start to be thinking about it. but not just saying how long you're going to be here, why. what is it that we think some of the milestones are going to be so that i engage you in that and you share with me whether you think that that's going to make sense for all of the things

you've got in the community that are a challenge for you as well. and i think that's hard when we start that conversation and they feel like they've-- people have spent so long waiting to get here. the first thing we say is, "and now let's talk about your discharge." and yet it's something we know we need to do because people are coming to us with more complex medical and psychosocial situations

that it's going to take us more time to actually get the right plan together with you so that you can actually stay at home and be as well as you can be at home. but it's kind of hard because i don't think people have caught up to that idea, and we need to do a better job at explaining why we're talking about discharge when you just got here. (patti cochrane) yes, for sure.

so, can you talk to me a little bit more, michelle, around home first, the home first philosophy. (michelle draper) sure, i'd love to. it's actually a provincial initiative. and we have just done a home first refresh this past fall. and it is really engaging patients and their families in the beginning as part of the team to talk about, "what will it take to return home?"

and it's looking at maximizing every single strategy we have with those community partnerships, with also getting families to think outside the box in terms of what resources or what supports that they can actually mobilize for them. so that they can be thinking about, "i know i'm here. "and i know i might be struggling "with multiple complex issues, but i'm going to go home. "and from that point, if there are other things

"that i need to be thinking about "in terms of a retirement home, or an alternate level of care, "a facility that provides more assistance, "i'm actually going to do that big family planning decision from home." so it's having that conversation that everything we're doing is really trying to make sure it's about home. and doing that, we actually try to unearth what other resources people might have that they've never even thought about

to make that happen in a safe and positive way that includes quality of life and getting back to your home. (patti cochrane) so partnerships are very important as we move forward on safe discharges and transitioning to home. any particular partnerships in particular that we work with? (michelle draper) well, i think, i mean, the obvious one is certainly community care access centre and our partners in the sdl, supports for daily living.

so we work with a lot of different supports. probably ryan and nadia are the best to identify that. but what we try to do, too, is when teams identify that if a resource like x would be useful, is to go out and see if we can find some more as well and partner with them. but you guys probably have a better menu of resources that you guys turn to. (ryan gostlow) there's a lot of specialized resources

depend on what area you work in. so i work mostly with individuals on the neurosurgery side of things, so brain tumors and brain injuries. and there's several community partners with which we work, like the peel halton dufferin acquired brain injury services, an excellent service. and if i could say if anybody needs more funding, it would be them.

because they're excellent for our patients. but without community partners, the transition piece is almost impossible. and without specialized community partners it becomes even harder, because not many people understand what it's like to live with a brain injury. and to get home, people need education and understanding. i can only provide so much in the limited amount of time they're here with us in the hospital,

as can the physicians and the rest of the team members. and so what an organization like phabis, or like chirs in toronto, does is it helps people understand, "this is what your journey's going to look like from this point forward." and it helps to not only have them thrive in the community, but also keeps them from returning to the hospital if they encounter a situation which they're not sure

what to do with. (patti cochrane) seema, we recently worked very closely with our ccac partners on something called "seamless transitions." and what did that really do? i think what it was intended to do was work more closely in partnership with our ccac partners, who were actually probably the other key player in our whole discharge planning team. so what were some of the findings in that work?

(seema marwaha) well, so seamless transitions, i think, is one of many projects that is going to be coming down the pipeline that tries to look at patients holistically. so recognizing that, like, sometimes in the hospital we see patients when they come in through the emerg, and when they leave, when they're discharged, that's sort of our interaction with them. but we're recognizing that, you know, patients had a life prior to coming in.

and they had services in place prior to coming in, and those have to be continued when they go home. and so seamless transitions, what it really tried to do was make a link between their community care and their hospital care. and the interesting thing is i think it actually did have a significant reduction in return visits to the emergency department and readmissions. and so it's interesting, 'cause that's some low-lying fruit.

like, if it was communication and lack of understanding of care in the community that was really a problem, then seamless transitions i think addressed that. one of the challenges that i have as a physician is that i really don't understand exactly what it's like for patients and physicians in the community. like, i think i know, but i really understand the hospital side of care a lot better. and it wasn't until i started doing home visits

that i really actually saw what it was like when patients are discharged home. and it made me practice differently. so i think that any time we can kind of replicate that learning experience for people that work in acute care, i think it will result in a better system. (patti cochrane) totally. i think that's so important. so partnerships into the community and actually gaining that experience

in patients' homes is really valuable as we look forward. well, i want to thank you for joining us at "talk trillium." it's really reassuring for us to know that patients and families have a whole entire team that help them in their transition from hospital to home. and we look forward to hearing more about the work that you do into the future. so thank you so much for joining us here.

(ryan gostlow) thank you. (patti cochrane) thank you. thank you. (patti cochrane) welcome back to "talk trillium: partnering for patients." at trillium health partners, our staff, doctors, volunteers, and students are dedicated to creating for today's "faces of trillium" we will learn about the different roles of pharmacy at trillium. today we will hear from eric post, who is the retail pharmacist at the credit valley hospital.

and eric tells us about the services provided at our retail pharmacy. next, we will hear from steve celetti, a clinical pharmacist here at trillium who works with our patients and their healthcare team throughout their stay at the hospital. (eric post) my name is eric post, and i am the pharmacy manager at the guru nanak dev pharmacentre at credit valley hospital.

i've been here since august 2012. so here at the guru nanak dev pharmacentre we are a retail pharmacy. we service patients that are on discharge. we service patients that go to the oncology centre. we service patients that go to the renal centre, along with staff and volunteers and other members of the community. just like any other retail pharmacy,

we provide these patients with retail pharmacy services for a large variety of things. we also sell home healthcare aids. and we also sell bracing, as well as over-the-counter medications. we are a retail pharmacy. however, we do have a little bit of a specialization compared to most retail pharmacies out there. because we are here in the hospital

and a large part of the hospital ambulatory care is renal and oncology, we have a very large number of patients that we service in those demographics. so, as the pharmacy manager here, i oversee all of the staff. so i take care of scheduling. i take care of inventory management along with my staff. i also dispense a number of a days a week.

so i am actually the pharmacist on duty. so one of the things that i really enjoy about being here is interacting with our patients. it is the reason i went into pharmacy, is i always wanted to be, and i always knew i wanted to go into something to help people in the healthcare field. and i always thought pharmacy would be an interesting thing. it's very gratifying to have a patient come in and know

that you're making a difference to them in understanding how they are to take their medications and how those medications are going to help them get better. i originally started my pharmacy career as a pharmacist in ottawa. after about a year and a half i moved to london and spent about 8 or 9 years in london working with shoppers drug mart and other pharmacies in the area.

then my family and i decided we wanted to make a change. and my wife had a great opportunity in toronto. so we decided to move to the area. we have a child who's just under two. so we currently spend a lot of time just hanging out with our child and enjoying our evenings and weekends with her. we do like to do a lot of camping and a lot of outdoor activities in the summer, as well as in the winter we like to go skiing,

cross country or downhill. all pharmacists do counsel patients about their medications. and that's one of the most important things that we do. so it's important to be attentive during that counseling with the pharmacist because we want to make sure, as a pharmacist, that you understand how to take your medication to get the maximum benefit. in addition to providing information about just

the basics of how to take it and when to take it, we want you to understand, you know, when the benefits will kick in for that medication, as well as what to do should any side effects occur with that medication. a few years ago the ontario government gave community pharmacies the ability to administer the flu shot. it's a great service that a number of pharmacies in ontario now provide.

but here at the pharmacentre we do offer at that service. it depends on the year, but generally, we do several hundred. so i would say anywhere from 500 to 600 flu shots every year are given here at the pharmacentre. there are no costs to the patient for the administering of the flu shot, as that's covered by the ontario government. so it's a great idea for all ontario residents to go out

and get that flu shot to help protect not only yourself but others that may be more vulnerable to the flu. i think we have a great team here. everybody's very caring and very patient and very understanding of the needs of the patients that we serve here at credit valley hospital. (steve celetti) my name is steve celetti. i work at the trillium health partners credit valley hospital site as a staff pharmacist

covering general medicine and rehabilitation units. our main role is to provide effective and efficient drug distribution services, as well as looking for drug therapy problems on all of our inpatients while i'm covering one of the inpatient units. so, actively looking through charts, speaking to patients, and connecting with the team in order to provide the best pharmaceutical care that we can.

so when i first come in i would work the patient up, do a comprehensive work up, looking through the patient's history, which medications they're currently on, looking for any sort of drug interactions, making sure that the doses are appropriate, as well as the frequency and duration of those medications. i would speak to the patient as well

to see if they are improving with therapy. we actually interact with a lot of different team members throughout the hospital, interact with fellow pharmacists as well as we're closely working with our pharmacy technicians, who you can see here in the background. we work together with the physicians, the nurses, and all other allied health team members in order to deliver appropriate care to each patient. each day has a brand-new challenge.

we can be asked many different drug information questions, some that may have very limited information in terms of what we can research, as well as just linking the patient with the medication. sometimes it can be difficult just to acquire a medication. it may be something outside of the country that we require special access from health canada. it may be something that might be quite expensive. so we look for ways in order to provide that medication

to all of our patients. i like to prioritize all of my problems. and the ones that are most urgent, the ones that will be affecting the patients the most, are the ones i tackle first. so, for example, today i was looking at acquiring a medication through the special access program for one of the physicians for a patient who will be soon admitted to our hospital

who will be having surgery here. and i just wanted to make sure that that transition was seamless. it's always the patient first. when i was being educated at the university of waterloo that was the main focus, was patient-focused pharmaceutical care. after i graduated from the university of waterloo, i then went on to a one-year residency training program here

at trillium health partners, but at the mississauga hospital site. and that's where i had intensive training about what it takes to be a clinical pharmacist, the things to look for, situations that i might find myself in, and really how to use all of the information and resources to best help the patient in the most effective and efficient way. well, i'm from northern ontario, sault ste. marie.

so, of course i play hockey. and i still play hockey both winter and summer. that's never stopped and probably never will. i love playing all types of sports. so i've also volleyball in the last couple of years, softball, anything that i can really get my hands on and stay active. i definitely promote living healthy, so i have to be that example as well.

i feel great doing what i do. i know i wake up every morning, and i'm excited to come to work because i know i'll be helping people. and also, it's very--it's a very stimulating environment. there's always something different, a new challenge every day. so i always look forward to those challenges. (patti cochrane) oftentimes the members of our community have questions about what to do when they get to the hospital

as a patient or as a visitor, what services are available, and how to access them. stay tuned to hear our staff and physicians answering those questions. and don't forget to watch to the end for "tick tock trillium," where dr. seema marwaha, one of trillium health partners' physicians, who was also a scientist at our institute for better health, tells us the difference between a nursing home

and a retirement home. if you have any questions that you would like answered, please send us an email at: talk.trillium @trilliumhealthpartners.ca take a look at our "community q&a." (david longley) the process for planning new hospital development in ontario is governed by the ministry of health and long-term care. and so we work very closely with the ministry and the mississauga halton lhin.

we start out with very high-level planning documents, which we submit to the ministry and to the lhin. we receive their comments and their feedback, and we make changes as appropriate. and then we progress on to ever more detailed stages, eventually into detailed design and construction of the new facility. this is one of the most complicated aspects of planning a new hospital.

first, we start with population projections, which are relatively straightforward. we have a fairly good idea of the future makeup of our population in terms of how many people will live in the area, whether they will be male or female, approximately how old they will be. that part's relatively straightforward. the part that's very challenging is to determine

at what rate those future populations will utilize health services. because we know it won't be exactly the same as we utilize health services today. and so, for example, the province of ontario has far fewer inpatient hospital beds than it had even 30 years ago because we do a lot more work in ambulatory and outpatient settings than we used to. and so predicting how those trends

will continue into the future is one of the biggest challenges that we face. we do our best to talk to our clinicians, to look at other patterns around the world, and to read the literature. but that does describe one of the most challenging aspects of planning future hospital capacity. so, firstly, we plan all of our work well in advance. there are a number of stakeholders in the hospital,

such as our infection prevention and control department, as well as our occupational health and safety department. and, of course, the areas that we are doing construction in, and the folks that operate those areas, we all sit down together well before the work commences to review what needs to be done, to think about the measures that we need to take to keep both visitors, patients, and staff safe during that work. and so, just as an example, we recently were doing some work

at our credit valley site, and we knew the work would be very noisy. so weeks before we had to do this work, we did do a test of the noise levels to see what the impact would be to patients in those areas. we were able to determine that in some of the areas the noise exceeded the levels that we would want for our patients. and so we were able to, ahead of time,

move those patients so that when the actual work was being done, there were no patients in the area. so the first thing that we have to consider is that we require absolute reliability of our electrical system. when the electricity fails in your own home it may be inconvenient, but it probably poses no real danger to you. whereas here at the hospital, an electricity failure is potentially very dangerous for our operations.

so, firstly, we have two main feeds that come into the hospital, one from the east and one from the west. so hydro one controls that for us. if they have a power outage in one part of the area, they can switch feeds for us to give us reliable power from the other feed. and then, secondly, we have emergency diesel generators here on site that run all of our critical equipment.

they don't supply power to everything that we supply here at the hospital, but they do supply power to our operating rooms and to some of our critical air handling units that supply and circulate air throughout the hospital, as well as to critical equipment such as computers that are on nursing units, and ventilators that are treating some of our critically ill patients.

(seema marwaha) sometimes people use the terms "retirement home" and "nursing home" interchangeably. but they are actually quite different. a retirement home is a placement for senior citizens who are well and can live independently. retirement homes are actually privately-owned residences, not owned or operated by the government. seniors rent out the apartment they can afford, just like any other rental building would operate.

so, who pays? the residents pay for the accommodations out of their own pocket, and the cost varies. there is usually the flexibility to pay for extra help and medical services if needed. there are a number of private retirement homes in the gta, and many have no waiting list. long-term care homes are often called "nursing homes." unlike retirement homes, nursing homes are required

to meet the medical needs of their residents. it is really meant for people with more medical complexity or higher care needs. they provide 24-hour nursing care and supervision. you need to be assessed for eligibility by a doctor or nurse in order to apply for a nursing home. these homes receive government funding, with residents paying a co-payment for accommodation that is consistent across ontario.

most homes are at capacity, and there is likely to be a waiting list for admission. so nursing homes and retirement homes are actually very different. for more information, you can check these websites... (patti cochrane) welcome back. this concludes our program, and thank you for watching "talk trillium."