2019 Ingenious Large Public Sector Award | Humber River Hospital’s iPlan solution
Getting patients who don’t really need to be in hospital transitioned to alternate settings is a huge challenge for hospitals. These patients, dubbed Alternate Level of Care (ALC) patients by the Ontario Hospital Association (OHA), occupy beds that could be used by those needing inpatient care and are the leading contributor to capacity challenges and hallway medicine according to the OHA.
The target ALC rate (number of hospital days used by ALC patients divided by total inpatient days) for Ontario hospitals is 12.7 per cent. However, Humber River Hospital (HRH) averaged 16 – 17 per cent; making it one of the worst performers in the province.
“More and more we got together as a group within our LHIN (Local Health Integration Network – the Central LHIN, of which HRH is part, includes nine hospitals plus many other care services) and it was evident that we had no standardized processes and everyone was really struggling,” said Carol Hatcher RN BN MN, vice-president of clinical programs at HRH. “It was a bit of a black hole with regards to any sort of system decision-making.”
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“We didn’t have a lot of data to understand the challenges that patients are experiencing,” added Mehdi Somji MHI CHE, director integrated health systems and partnerships. “Those patients we can’t get out, it comes down to one of two things: either a process issue or a system issue.”
Process issues, he explained, look at how effective the hospital is in getting patients to their next level of care. System issues are harder to fix – if a patient needs to go to a rehab centre and there’s no capacity there, then there’s nothing the hospital can do.
In collaboration with five of its LHINs (North York General Hospital, Markham Stouffville Hospital, Southlake Regional Health Centre, Mackenzie Health, and Central LHIN and Community Care), HRH leveraged the Cancer Care Ontario ALC Leading Practices User Guide to develop the Discharge Planning Pathway, a set of workflows that would make hospital processes more efficient.
“But we noticed that it was still quite challenging to know, have we implemented the right processes,” Somji said. “We’re not really able to measure those, and that’s what kind of led into the development of iPlan. So in iPlan, you’re actually able to see all of your patients, as well as look at the workflow and how they’re transitioning through the hospital. If they’re missing any of the key elements within the processes, it’s flagging and highlighting it for the staff.”
As well as automating the Discharge Planning Pathway, iPlan was built to integrate with any system, including the hospital electronic medical records (EMR), to centralize all discharge planning information from the hospital and the community. A dashboard shows activity across the LHIN in real-time. Hatcher said this is unique; many other systems of this kind are retrospective, with an average two-month lag.
The system itself was developed internally, with the hospitals gathering requirements collaboratively and then having a software engineer build it using the .NET Framework. The interface is a web-based portal accessible through the hospitals’ intranets. The physical infrastructure resides at HRH.
Results so far have been impressive: one-year post-implementation, HRH experienced a 4,458 decrease in ALC days, the equivalent of freeing 12 beds for acute care, at a cost avoidance of an estimated $3,254,340 (based on the average cost per day of $730 per ALC patient). The ALC rate decreased by 2.4 per cent. The system is now in use in several other hospitals in the LHIN, with interest coming in from across the province.
There are many benefits emerging from the system, but the biggest was ensuring that every patient goes through the same process, Somji said.
“It’s really sticking to those principles of high reliability,” he explained. “Every patient that comes in will have an assessment done on admission to see if they need any sort of services with early intervention to ensure that there’s minimal waiting for them transitioning out. That results in the decrease of those ALC days, avoidable ALC days, we would say. I think that’s the biggest impact, and really ensuring that no patient falls between the cracks.”