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Teresa Gehman, Project Manager and Allyson Shpirko, Patient System Navigator from the Thunder Bay Regional Hospital visited Keewaytinook Okimakanak teams in Balmertown and Sioux Lookout this week to share information about their project - the Regional Patient Coordination Project. A videoconference with Community Telehealth Coordinators in northern First Nations and other interested participants is planned for 3:30 pm, Thursday, Oct 18 to discuss this project and the opportunities for serving patient needs in the far north.

EMERGENCY SERVICES NETWORK –
REGIONAL PATIENT COORDINATION PROJECT

In January 2007, Thunder Bay Regional Health Sciences Centre in conjunction with several regional healthcare partners submitted a proposal for the development of a health services network focused on promoting existing alternatives to hospitalization, and the introduction of regional health system navigators. The ultimate outcome for this project is to initiate changes removing the “open to select referrals” pattern that occurs when TBRHSC Emergency Department becomes overwhelmed. TBRHSC is the only acute tertiary site for the North West LHIN, and the goal is to fully respond to the needs of the region and provide equal access of care to all patients within our region. It is important that we determine best practices to accommodate these new initiatives within our organization and then work with our regional partners to flow out patent care methodologies.

Recognizing that the LHIN strategy is to collaborate with healthcare providers to implement system changes improving access to care across the Region, the strategy proposed in this project proposal focuses on how TBRHSC can: 1) improve its own competencies and capabilities; and 2) collaborate with regional partners to improve, develop, and strategize process and systems management methods that improve patient care and movement throughout the North West. While the intent is to create a systems management process for the region, the impetus for this project focuses on the role that TBRHSC plays as a regional tertiary hospital. The scope of this project is bi-directional between TBRHSC and partners; it is not the mandate of TBRHSC to develop regional communication strategies. Through the process of developing the systems management structures, there may be coordination and standardization of certain policies across all boundaries of the regional partners. These standardizations would take place in order to provide consistencies in patient care and movement.

Project Initiatives

The Regional Patient Coordination Project proposal outlined three major initiatives:

• The creation of a North West LHIN-wide Network among existing health care providers across the continuum to :

a. Review inpatient and emergency room utilization across the region.
b. Identify clinical categories where actual lengths of stay (LOS) exceed the expected LOS; identify admissions that did not require hospitalization; identify those case mix groups where there are high readmission rates.
c. Create time-limited task forces in priority areas to develop mechanisms that improve patient management.
d. Create mechanisms to share solutions developed by the task forces with local and regional providers.

• The trial of patient navigators. One navigator will focus on the needs of the population in the greater Thunder Bay area, and the other navigator will focus on the needs of the population living in the Northwestern Ontario region. Situation of both positions are at TBRHSC to facilitate patient management to the most appropriate placement or care level post discharge from acute care and emergency services at TBRHSC.
   
• The creation of four task forces. The content analysis of data received through the various feedback modalities clearly indicates several needs. These include the development of supportive education in the region to healthcare providers, development of communication strategies to facilitate the transfer of knowledge for both patient care and best practice methods, and a systems management process that builds continuums for patient care across various healthcare and social agency levels. In order to address issues identified through both the feedback modalities and interviews with Departmental Managers and Directors at TBRHSC, the Executive Team is recommending to the Regional Emergency Network to create four task force groups for this project. These task force groups may decide to focus on specific CMGs in order to develop the processes and strategies for patient care and management.

a. Federal First Nations
b. Discharge Planning
c. Standardization of Policies and Procedures
d. Strengthening our Partners

Patient and System Navigators

The Navigators will be a resource to facilitate transfers, admissions, and discharges to the region and access both inpatient and outpatient resources. Outcomes are to improve timeliness of care, and effectiveness and efficiency of care as articulated in the LHIN’s IHSP (2006). Using the thematic content derived from the various feedback modalities, the Navigators will focus on the facilitation, improvement, and development of communication procedures and system management methodologies between TBRHSC and local and regional partners. These individuals are not engaging in direct patient contact. Instead, the Navigators will work closely with Utilization Coordinators and other nursing, medical and allied health staff to improve the ability of patients to receive timely and necessary medical treatment within the North West Region, and develop and strengthen methodologies to provide patients with alternative healthcare resources other than the Emergency Department.

The Navigators will:

•  Complete a full environmental scan of local and regional healthcare and social services that Northwestern Ontario provides. This environmental scan includes but is not limited to understanding the referral patterns physicians use in transferring patients to and from TBRHSC, the provision of healthcare services within regional community hospitals, where do regional community hospitals feel they are lacking in competencies in healthcare delivery, resource restrictions, communications between regional and TBRHSC healthcare providers, and social services supports.
• Using current practices, best practices, and existing policies and procedures, strengthen accountability and governance structures to facilitate easier patient movement throughout the healthcare and social support systems.
• Determine methodologies to support local and regional partners’ healthcare competencies and practices so that patients not requiring tertiary acute care hospitalization are able to receive services in their homes or regional community hospitals.
• Working with tertiary level healthcare providers (Manitoba, Southwestern Ontario, northern United States), facilitate processes and systems to repatriate patients back to Thunder Bay, or bypass Thunder Bay to home community hospitals depending upon level of care required for the patient.

The Regional Navigator will:

• -Build on existing relationships with all 12 regional community hospitals, North West CCAC, Nor’ west CHC, Health Canada nursing stations, and Family Health Teams, and develop new relationships with Aboriginal Health Centres and healthcare providers, primary care providers and social services agencies to ensure a better understanding of how to achieve alternatives to hospitalization. The Navigator position will continue to enhance the existing linkages between organizations across the continuum of care.
• Collaborating with various departments throughout TBRHSC and regional partners to coordinate and develop patient care system models both internal and external to the TBRHSC organization.
• Collaborate with various departments throughout TBRHSC and regional partners improving access to existing outpatient clinics in order to avoid in-patient admissions and readmissions.
• Recognizing unique challenges exist to deliver healthcare in First Nations’ communities, the Navigator will work with multiple levels of healthcare governance to facilitate the ability of patients and their families to receive timely care and repatriation to their home communities.
• Work with various departments throughout TBRHSC and regional partners to develop education materials for caregivers, patients, and healthcare providers on services available to them within their regional healthcare centre.