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CPSI Share                                                  
11/2/2016 7:00 AM

Congratulations to University Health Network (UHN) Toronto Rehab's Lyndhurst Spinal Cord Rehabilitation Team, who received honourable mention for the 2016 Team/Organizational Champion Award for creating a discharge process that ensures a safe transition between inpatient rehabilitation and the community.

Transitions of care, particularly at discharge, are a vulnerable time for patients and it does not always go smoothly. Safe transitions can be compromised and lead to hospital readmission when patients are inadequately prepared for discharge. The Spinal Cord Rehab Team at Toronto Rehab's Lyndhurst Centre ensure the uptake of self-management skills such as medication management, early detection of symptoms to look out for, and who to contact in case of complications to ensure safe transitions between inpatient rehabilitation and the community.

Sandra Mills and Heather Flett co-led the Patient Orientated Discharge Summary (PODS) pilot project to develop and implement a discharge process in a spinal cord rehabilitation context. The PODS is a simple tool and set of process changes that was co-designed by patients and providers. The feedback from patients and clinicians who participated in the pilot was overwhelmingly positive.

In May 2016, the pilot program transformed into a new standard-of-care at Lyndhurst Centre, making it the first self-management tool of its kind in Canada for spinal cord injury patients using PODS in a teach-back style meeting.

"The PODS meeting is oriented to the patient to consolidate their learnings," says Heather Flett, Advanced Practice Leader in Spinal Cord Rehab. "The PODS meeting is not a discharge planning meeting. We already have a meeting with patients and families and the entire Interprofessional team to talk about the discharge. The PODS meeting focuses on self-efficacy to determine if there are things that the patient has not clearly understood that can be addressed before discharge."

The PODS process includes a written summary presented in an easy-to-understand format covering five key areas and a teach-back approach to educating patients. The first of the five sections in the spinal cord injury-specific PODS relates to medications and generates a conversation about a person's confidence and ability to manage their medications, as well as accessing bladder supplies once at home.

The second section is the Care Plan. It  covers issues specific  to spinal cord injuries, including swallowing and breathing, skin, bladder, bowel, pain, memory, dressing and bathing, eating, mobility and transfers, equipment, shopping and cooking, housing, relationships and coping, transportation and leisure. "We ask questions, such as what is your plan for managing your bladder at home and the individual will then teach back their learnings from rehabilitation," says Sandra Mills, Patient and Family Educator at Lyndhurst Centre. "Teach-back validates the healthcare provider's ability to educate the patient and identifies what the patient knows or doesn't know so that we can close that gap prior to discharge."

The third section addresses signs and symptoms and what to do. The content identifies worse-case scenarios that patients may need to work through at home, such as increased swelling or, pain, urinary tract infection or a fall, etc.

The fourth section lists outpatient referrals and appointments. The project team found that patients liked having their appointments and referrals summarized in one spot to know exactly what they need to do during those first few weeks at home.

The final section provides a My Contacts list. "This is one of the most valuable pieces of the patient's take-away," says Sandra Mills. "It is a complete list of contacts customized for that individual so that when they go home, they know exactly who to contact if they have a question or problem. Those contacts include both people here at Lyndhurst and people in the community."

Funding for the original PODS pilot project was provided by UHN OpenLab, a design and innovation shop housed at the Toronto General Hospital that is dedicated to finding creative solutions that transform the way health care is delivered and experienced. "We received early-adopters funding from the Toronto Central LHIN and were able to secure a project coordinator and two patient advisors to move the project forward in a short timeline," says Sandra Mills.

Two former patients with spinal cord injuries were an integral part of the project team and true partners in the project design, development and implementation. "We looked to our patient advisors for their thoughts on content, how to ask questions and ideal format of a PODS meeting," says Heather Flett. "The patient advisors conducted Focus Groups, did in-person and telephone interviews to seek information and validate the PODS template. When talking to other patients they could relate to them from their experience and the information gathered was a lot richer information than only that obtained from healthcare providers."

Joanne Zee, Senior Clinical Director, Brain and Spinal Cord Program at Toronto Rehab's Lyndhurst Centre nominated the PODS team for the 2016 Team/Organization Champion Award. "Patient engagement and co-design transformed a simple discharge summary into a discharge process that is centered on the patient and focuses on safety, self-management and confidence-building," says Joanne Zee. "Engaging patient advisors as members of the team to better understand the needs and experiences of patients was invaluable to shape the outcome of a safer discharge system."

HealthCareCAN and the Canadian Patient Safety Institute have partnered to present the Patient Safety Champion Awards to recognize champions of patient safety - volunteer patient or family members and teams or organizations who demonstrate exemplary leadership and collaboration to champion change and achieve safer care through patient/family engagement. The Team/Organizational Champion Award recognizes a team or organization who, through exemplary patient centred care and patient engagement practices, contributed to a project or initiative that resulted in identifiable positive impact on patient safety outcomes.