Written by Lisa Bournelis, Senior Consultant, Strategic Transformation Team

How Chilliwack Health Services teamwork transitioned a patient from immobility to independent living.

Reducing the length of stay for patients in acute care requires ingenuity and collaboration. Chilliwack Health Services demonstrates that no matter how complex a patient’s situation, bringing together a team that is committed to partnering with the patient results in both better health and better health care. They follow a simple rule: no matter how patients present upon admission, understanding what their goals are immediately in the care processes, and partnering with patients in their discharge journey, is what patient-centered care is all about.

Here’s an example: 68-year-old Ms. A came into Emergency after a fall in her independent living suite. Dependent on an electric wheelchair for over 30 years, she had just fractured her knee. At the start of care, nurses were using a ceiling lift to transfer her out of bed to use the toilet. She was transferred to a transition-to-home (PATH) unit, where the team collaborated during weekly complex care rounds to work with her on a plan that was specific to her unique needs.

Her goal was clear: to transition back to independent living. Occupational therapy provided assessment and recommendations for appropriate equipment, physiotherapy worked on the goal of independent transfers, and nursing supported Ms. A to self-manage her care where appropriate. Home Health worked with the community case manager and community physiotherapist to ensure the supports were in place on discharge.

Despite the intense winter weather, Ms. A was discharged with four daily home support visits. The discharge coordinator liaised with community pharmacy to have her medications packed and sent to her living centre, spoke to the centre’s manager to ensure a medical alert pendant and meals were in place for her return, and arranged for community physiotherapy to visit her within days of her discharge home. Ms. A was visited by the Quick Response Professional who report that the team’s efforts in transitioning home were successful.


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