Creating a system that helps patients move from an acute care bed to another, more appropriate level of care is a complex task. While there are a number of reasons this occurs – from lack of availability of a bed in the community to a lack of beds in hospitals – care and efficiency can be affected as patients wait to be transferred or discharged. However, through collaborative planning and the application of appropriate information systems, care managers are better able to identify transfer or discharge needs and the availability of appropriate resources earlier in the patient’s treatment, resulting in better referral decisions, an increased number of completed referrals and a better use of resources and system capacity.
The Erie St. Clair LHIN received funding to plan a comprehensive resource matching and referral system (RM&R) to develop an RM&R road map. The scope of the plan covered four pathways: Acute to Comprehensive Complex Continuing Care; Acute to Rehab; Acute to Long Term Care; and, Acute to Home Care.
Because patients and patient care are not bound by geography, this work was done in collaboration with the South West, Waterloo Wellington and Hamilton Niagara Haldimand Brant LHINs. A joint Steering Committee was established to guide these activities across regions and CHIS’ Project Management Office led the first phase of this project for all four LHINs.
Subsequently, the RM & R initiative was identified as a priority project by all of the 14 LHINs and in November 2010, the Ministry of Health, Health System Accountability and Performance Division appointed the Toronto Central LHIN to act as the Project Sponsor for the Provincial RM & R Project. A Provincial RM & R Steering Committee was struck to provide strategic and operational guidance on the project. Stephen Banyai, CHIS President and CEO is a member of the Provincial Steering Committee.
For local and regional activities, LHIN clusters have established local governance structures that incorporate representation from across the involved LHINs and their health service providers.
To date the ALC RM & R project has resulted in the development of provincial guidelines referred to as the Provincial Reference Model. All LHINs have completed current state assessments of their existing referral processes. LHIN clusters are being mobilized to complete the remaining phases that are required for broad RM & R implementation.
The Ministry and the project sponsor are currently developing implementation timelines and costing models for implementing ALC RM & R and consultations took place to determine a preferred approach to implementing the RM & R solution (ie. one solution provincially or multiple solutions provincially based on clusters). Membership of the Erie St. Clair cluster includes the LHIN CEOs from ESC and SW, as well as CCAC CEOs, LHIN CIOs, and representation from the Provincial Steering Committee, including Stephen Banyai, President and CEO, CHIS. CHIS is supporting the work of the cluster Steering Committee, which meets regularly.
Read the latest updates on the work of the ALC RM & R Cluster Project led by CHIS: