Theme 5. Optimizing use of resources
The Algonquin FHT developed a Discharge Patient Program to meet the needs of our patients, recently discharged from acute care, to support their seamless transition back into primary care. We identified gaps during this transitional period, which negatively impact the patient’s ability to stay safely at home. These identified gaps could lead to repeat ER visits and readmission to acute care. The Discharge Patient Program RN has real-time access to the local hospital’s daily discharge summaries and in-patient charts. HRM is installed in our EMR which allows for timely access to our patient’s discharge summaries. Utilizing these available resources, our RN is able to build a complete patient history and thoroughly prepare for a telephone-based holistic patient assessment. The RN identifies and pro-actively resolves any high-risks that might lead to a hospital re-admission including: 1. Best possible medication history, 2. Symptom review and management, 3. Assessment of safety at home 4. Assessment of need for referral to community agencies or FHT supports, 5. Booking follow-up appointments with the PCP including urgent and home visits as needed. The RN provides timely consultation with our physicians, pharmacies, CCACs, community supports and FHT programs to support the patient’s safe return home. Huntsville is a rural community with limited resources to support our patient’s successful transition home post-acute care discharge. Our Discharge Patient Program, through early assessment and identification of high risks to re-admit, prompt medical interventions, promoting patient self-management and preventing medication errors, shows remarkable results that support our patient’s safe return home and prevent hospital re-admissions.