Integrated Care Solutions

Saint Elizabeth Health Care works in partnership with hospitals, Regional Health Authorities, and others to design and implement integrated care solutions with practical, tangible results and improved outcomes for individuals, their families and the health system.

Working together, we ensure a clear understanding of the issues and their root causes, and with the combined experience and expertise, we develop customized solutions that are grounded in solid processes, policies, education and coaching that are required for successful implementation. A step-wise approach enables us to work initially with a smaller group of champions, learning from the initial testing and development, then refining as we expand to larger populations of clients and to other geographical areas, enhancing the capacity of local teams throughout the process. Ongoing monitoring and evaluation supports further refinements for even better results.

Some examples of these solutions include:

Discharge and Transition Programs

Our discharge and transition programs are aimed at providing individualized patient-centred care, while maintaining shortened length of stay; delivering cost-effective service in an appropriate setting; addressing ALC issues; increasing patient and provider satisfaction; and, ensuring a safe experience.

Hospital-to-Home
Saint Elizabeth Health Care offers a home discharge program that helps seniors and people with disabilities without adequate caregiver support return home and get settled safely after an Emergency Department visit or hospital stay. These individuals can be more appropriately served in the community, but may not have the supports needed after discharge. A dedicated team of PSWs accompany the patients home and ensure that they have adequate supplies and their prescriptions are filled. There is also follow up with patients to determine if there are other supports required, such as meal preparation, and housework. General safety checks are also conducted, including relocating the client to a safe location in the house and moving necessary supplies to an accessible area to allow the patient to remain more independent and safe.

Transitional Beds
Saint Elizabeth Health Care can manage the creation and implementation of transitional beds to enable the discharge of medically stable alternate level of care (ALC) patients who do not require admission to long term care, but are not yet ready for full discharge back into independent living. Transitional beds offer these patients assisted living type support and basic nursing services for a short-term period, during which time patients can complete their recovery. Care within transitional beds is focused on maximizing independence and planning for the final discharge destination, which is intended to be to independent living.

Objectives of this initiative include: reducing the length and number of hospital stays and Emergency Department admissions for those who are not in need of acute care services; facilitating safe and timely hospital discharge; increasing availability of beds in acute care; coordinating patients, caregivers, hospitals and community support staff to facilitate smooth transition from hospital to community; reducing system costs; and reducing hospital re-admission rates.

Early Postpartum Discharge
Saint Elizabeth Health Care works in partnership with hospitals to provide maternal-newborn nursing care for patients who meet the criteria for early discharge. Services may include physical assessments, general consultations, support and advice on feeding/breastfeeding, health teaching, telephone assistance and referral to community resources as required. A clinic model is used in order to service patients more effectively and reduce costs.

Objectives for this program include: maintaining shortened length of stay, reducing readmissions, ensuring patient safety, increasing customer satisfaction, enhancing the quality of patient care and providing individualized care.

Health Promotion and Prevention Programs

Wait Time Guarantee Framework
Leveraging our expertise in clinical practice guidelines, applied research and direct service delivery, Saint Elizabeth Health Care can assist in the establishment and implementation of a patient wait time guarantee framework. Such a model may include understanding and documenting the current situation and then building, testing and refining a comprehensive program of prevention, early detection, diagnosis, care, treatment and referral processes, as well as recourse options for patients when clinical benchmarks are not met. Based on the project requirements, our experts will work collaboratively with project partners, funders and health professionals in areas related to training, the transfer of knowledge and implementation of change initiatives to improve practices.

Learn about the application of the framework in the Manitoba First Nations Patient Wait Time Guarantee Pilot Project, a partnership between SEHC and the Assembly of Manitoba Chiefs, with funding from Health Canada. The project focused on diabetes, exploring the prevention, care and treatment of foot ulcers with the goal of developing a patient wait time guarantee framework that would reduce the significant impacts of foot ulcers and the disproportionate number of amputations.

Chronic Disease Management
One component within certain solutions is Saint Elizabeth Health Care’s Building Bridges to Better Health, a series of 2.5-hour workshops over six weeks where people with different chronic diseases meet to discuss and learn the skills needed to deal with their condition on a day-to-day basis in an effort to maintain and/or increase life’s activities and enjoyment. Groups of 12-15 participants learn skills to be better able to:

• Set goals and problem solve
• Manage difficult emotions such as frustration, fear, and isolation
• Cope with pain and fatigue
• Manage their symptoms
• Develop personal exercise and nutrition guidelines
• Utilize medication effectively
• Develop effective communication strategies
• Make informed treatment decisions
• Create Personal Health Directives
• Build a positive partnership with health care professionals

The accessible, low-tech, multifaceted approach used by Building Bridges to Better Health makes it appropriate for people of any age, background, disability or level of literacy. The program is not designed for any one condition, so anyone living with an ongoing health condition, as well as their partners and caregivers, can benefit from the skills taught during the program.

Building Bridges to Better Health is based upon Stanford University’s Chronic Disease Self Management Program (CDSMP), and taught by Master Trainers and/or Leaders who have been trained and certified by Stanford University.

This program is being offered on a charitable basis in communities across Ontario with the generous support of the Saint Elizabeth Health Care Foundation.