Registed Nurses' Association of Ontario

Care Transitions from Hospital to Home: An Opportunity for Learning

Danielle Lumibao, RN
Holland Bloorview Kids Rehabilitation Hospital

Holland Bloorview Kids Rehabilitation Hospital (HB) is Canada’s largest paediatric rehabilitation teaching hospital. We provide care to children with cerebral palsy, acquired brain injury, muscular dystrophy, amputation, epilepsy, spina bifida, autism and other developmental disabilities as well as complex chronic diseases. The children and families we serve at HB undergo multiple care transitions in their rehabilitation journey. A care transition is defined as a set of actions that are necessary to ensure that the coordination and continuity of care is safe and effective when clients experience a change in care needs, health status, healthcare providers and location (Registered Nurses Association of Ontario, 2014). One such transition is our weekend leave of absence (LOA) program. During this time, clients and families can spend a couple nights at home or in the community. This program provides an opportunity for families to progressively practice new skills and gain confidence in caring for their child as they prepare for discharge. Families have indicated that they value this opportunity yet, in spite of the program’s value and nursing support, education and coaching, the weekend LOA is experienced as stress-inducing and exploring practice improvements was necessary at this time.

For the past two years, HB has been working on a discharge pathway for clients and families. We have implemented a Transition Passport to help families organize their health-related information and prepare for discharge. We have also implemented a Patient Oriented Discharge Summary which helps guide and standardize the communication that takes place between nursing and families and summarizes key information at the time of discharge. The next area on the discharge pathway was to focus on the LOA process and begin updating this process in order to facilitate smooth transitions for our clients and families. The fellowship focused on developing evidence informed standardized processes in place of our current practice regarding leave of absences (LOAs) that was co-created with clients, families and healthcare providers. The learning and the efforts that arose from this work were targeted at addressing four specific areas: standardization, documentation, communication and education/teaching.

My overall goal was to increase my knowledge, skills and expertise in guideline implementation by addressing the identified organizational need of improving care transitions. This learning involved creating process refinements that incorporated recommendations from the “Care Transitions” practice guideline. I conducted a literature review and increased my knowledge of transition practices in other paediatric and rehabilitation facilities such as Sick Kids, Toronto Rehabilitation Institute, Sunnyhill Health Centre for Children and BC Children’s Hospital. Through this fellowship, I had the opportunity to strengthen my ability to purposefully select knowledge and adapt it to fit within the current processes and the culture within Holland Bloorview such that it addressed identified gaps. Evidence shows that standardized documentation and checklists facilitate effective communication amongst nurses and between nurses and clients/families 1. One aspect of the work done during my fellowship, involved applying and integrating this aforementioned knowledge and modifying it to address the needs of our clients/families and staff and incorporating it into established structures and process (eg. computerized documentation, workflow). Furthermore, this fellowship helped me develop a deeper understanding of the principles related to safe transitions and discharge planning. The need to emphasize and further enhance the nurse’s role as a teacher materialized in the process of developing electronic documentation templates, initiating policy revisions, employing different communication techniques (signage, tip sheet) and collaborating with several clinicians. In order for this work to make a lasting impact within clinical care, it must be combined with the application of enhanced teaching and communication techniques by nurses before and after each LOA. As the primary caregiver, nurses are in a unique position to recognize strengths, help empower our clients and families and provide preparatory guidance for discharge. Discharge readiness encompasses the client’s and family’s perception of preparedness, confidence and competence to manage care at home 2. The strongest predictor of readiness for a care transition is the quality of teaching 3. Teaching has also been identified as a parent empowerment strategy 2,4. Efforts to amplifying teaching roles will continue as part of the work being done through Holland Bloorview’s Nursing Vision and strategic planning that involves transforming care, leading the system, accelerating knowledge and inspiring our people.

Throughout the fellowship, current inpatient clients and families as well as parents from our Family Leadership Group were engaged and involved in creating practice improvements. They also provided invaluable input to the fellowship efforts. This demonstrates the importance of client and family centred care and partnership at Holland Bloorview. Clients, families (and staff) have identified a need to enhance the program name-"Leave of Absence (LOA)". As a result of this fellowship, there will be a new program name/term in its place. In the upcoming weeks, efforts will continue to be directed at incorporating the new program name/term, “Weekend Pass”, throughout multiple areas across the facility. This program name/term was voted on by Family Leaders (and staff) and was frequently noted within the literature and also aligns with practices at other paediatric and rehabilitation facilities. Opportunities for client and family engagement were introduced in the form of client room signage. At this time, initial feedback suggests that signage has prompted families to engage in conversations with nurses earlier on. The signage as well as recommendations for a standardized transition goal offer opportunities to introduce care transitions and consistently set expectations with clients and families at the beginning of their inpatient stay. Additional outcomes from this fellowship include a means to improve information exchange allowing for safe transitions in the form of a family tip sheet to be included within our welcome package, a draft medication list that is more family friendly and an instructive information sheet that will be provided to clients/families prior to going home for the weekend. Given that a majority of clients and families admitted to one of Holland Bloorview’s inpatient units participates in the weekend leave of absences (or passes as it will be referred to moving forward), their contribution is befitting as it directly informs and impacts care that they have received and/or would receive.

At Holland Bloorview, the entire interprofessional team has a role in partnering with clients and families to prepare for leave of absences and ultimately discharge. The team provides the client/family with teaching, training, supplies and equipment. My colleagues and I provide education on medications, symptom management, the use of equipment and mobility among other aspects of the client’s care. Therefore, practice improvements and recommendations as a result of this fellowship directly impact the work of the team members within Nursing, Pharmacy, Allied Health and Medicine. As mentioned in the previous section, my colleagues were involved in enhancing the program name. Soon, inpatient nurses will have two standardized electronic documentation interventions that are evidence informed and were created with feedback from frontline nursing and pharmacy. These interventions help
promote common language, guide conversation and help to limit the omission of essential information at a care transition. These interventions also provide prompts around medication review and provision thereby addressing reported incidents related to LOA medications. As a result of this fellowship, interprofessionals across the facility have an increased awareness of the gaps that existed in the previous LOA process and many have become inspired to work towards a future state. Recommendations for a standardized transition goal within our family team goal planning process will help bolster interprofessional collaboration and communication. My sustainability plan includes finalizing a revised policy, additional steps to improve communication and my plans to continue enhancing our roles as teachers through my involvement in Holland Bloorview’s Nursing Vision and working with others focused on accreditation and strategic planning.

The overall fellowship experience is one that has allowed me to grow both professionally and personally. As a Registered Nurse, I was able to use my knowledge of practice and process within Holland Bloorview to inform the direction of my efforts. As a frontline nurse, it has been immensely rewarding to be a part of change within my hospital and be able to see the effect that would have on my practice and on the clients and families I provide care for. Given the demands of the healthcare industry, at times it is easy to merely focus on what is in front of you. This project allowed me to take a step back and see the bigger picture. As a RNAO fellow, I gained a richer understanding of what my role as a nurse truly signifies for the client and family as they navigate their health/illness continuum. Through this fellowship, I developed a deeper appreciation for what is needed when one attempts to implement change particularly within practice, when coordinating several clinicians and when working through a system that has many moving parts. I can attest to the significance of leadership support in order to propel change forward and create a culture of acceptance. This fellowship has also increased my visibility within and outside of the organization allowing me to network and form new relationships and set the stage for future work.

Furthermore, I was able to learn about myself and challenge myself to think outside the constraints of what is possible. I was able to face my fear of public speaking and presenting. I gained confidence in my ability to affect change and I intend to continue affecting change through role modelling. There were several moments I enjoyed throughout this opportunity including meeting various clinicians throughout the facility and externally as well as collaborating with clinicians that I would not have otherwise had the chance as a staff nurse. I enjoyed learning about the similarities and differences in care transitions across other paediatric and rehabilitation settings, learning a new set of communication skills and hearing about how excited people were for change. I am grateful for this unique learning opportunity from the RNAO. This has been a positive and enlightening experience for me within my nursing career.