Transition from hospital to home had always been stressful for both patients and their families and therefore, the improper coordination and transition planning can result in adverse events and unnecessary hospital readmissions. British Columbia has been the province with the second highest in readmission rate in Canada. Annually, 9.6% of Canadians gets readmitted to the hospital within the first thirty days after their initial discharge with a vast majority of this population being seniors (Fayerman, 2018). According to Canadian Institute for Health Information (CIHI)(2012), 59% of hospital readmissions are preventable with a seamless transition/discharge plan. As a Care Management Leader for the hospital, I must create a seamless transition plan by performing a thorough assessment of the patient based on the Social Ecological Model.
Figure 1: Readmission Rate Across Canada from CIHI, 2012
The Social Ecological Model (SEM) is a framework illustrating that one’s health is influenced by five multi level factors: individual, interpersonal, organization, community, and public policy. There’s an interrelationship between these multi level factors and each level shares the same importance as the other. Figure 2. illustrate the meaning of each level (World Health Organization, 2019). Instead of looking just at one’s biological and physiological determinants, the SEM understands the importance of social determinants of health. The model presents the complexity of how a health issue is developed and how it can be prevented through close examination of one’s social structure. For this blog, we are going to discuss how British Columbia’s (B.C.) senior Social Ecological Model affects the transition planning and how it can prevent hospital readmission.
Figure 2: Social Ecological Model and Description of Level
Individual
Patient’s willingness to participate, medical history, financial status, culture and language assessments are vital in this level. Patient’s participation is the number one criteria for a successful discharge planning. Legally, patient has the right to refuse care. If patient refuses to collaborate or adhere to medical treatments or suggestions, applying the other SEM levels will be a challenge. The planner must explain the consequences and try to find out the reason for care refusal. If patient accepts help, the next step would be to understand the patient’s medical history.
Understanding their medical history gives the planner an insight of their health and their functional capabilities to perform tasks. Common comorbidities that lead to hospital readmissions are COPD, heart failure, pneumonia, arrythmia and digestives disorders. Thorough community arrangements are required for seniors with these comorbidities (CIHI, 2012).
Financial Status is one of the social determinants of health. Due to government policies, the income disparity in British Columbia is quite significant comparing to other provinces. There are very wealthy individuals, but majority undergo poverty with most of them being the elder and disabled populations (BCNU, 2015). If patients are wealthy, they may be able to afford private support, which will cover up the community limitations; in contrary, if they are poor, then arrangements of programs and services will be required from the social work team.
Finally, Canada is a multicultural country with citizens who speak diverse languages. In 2001, 12.3% of the B.C. senior population are composed of visible minorities and therefore culture and language are imperative factors to consider when planning for the transition from hospital to home. Culture is one of the main social determinants of health (B.C. Ministry of Health, 2005). Culture and religion can affect one’s medical adherence and health attribution (Vaughn, Jacquez & Bakar, 2009). Language is the communication process for educating patients about their health choices. Without respecting one’s culture and language may lead to adverse events at home and transition failures.
Interpersonal
Understanding patient’s connections with friends, family and neighbours will be helpful in arranging supports to a patient once he/she is discharged from the hospital. The patient’s care giver can provide an insight of the patient’s daily routine and lifestyle which may help with discharge planning and community support arrangements. Also, the care givers’ opinion and insight is just as important as they can influence the patient’s decision and perspective of care (Russo, 2016). In addition, this is also the best time to assess for “care giver burn out”. According to Statistic Canada, (2015), 60% of care givers report distress while caring for their elderlies. If care giver burn out is noticed, planner must locate the stressor and try to ameliorate and, if possible, arrange for additional community help. If care giver stress issues are not resolved, health of both care giver and patient may be impacted negatively. Care giver's stress may be another reason for the demand of long term care as well (Statistic Canada, 2015).
If a patient does not have anyone to rely on as their aide, an increase of community support should be recommended to that patient. If patient refuses, the transition planner must explore the reason and work out an alternative plan together with the patient by laying out the risks that may causes detrimental effects on patient’s health. Regardless of the patient’s acceptance, the discharge planner must communicate with the community and family doctor about patient’s decision and, if possible, ask them to follow up in the community.
Community
Community support includes home support and services, community clinics and primary care providers. Follow-up after discharge is crucial. In BC, the most common cause of patient readmission is due to poor coordination with community services and follow-up (Fayerman, 2018). Before patient is discharged, the planner must provide a patient's update to the primary care giver and to the community support; in return, the community may voice out concern that they have from their previous experiences while working with the patient. Concerns may include patient adherence or resource limitation.
Availability of community resources is imperative towards a transition planning. In BC, large number of seniors from the rural areas get readmitted back to the hospital and that is due to limited resources. For this problem, the government has to implement better policies to hire more staff in these areas, as senior often stay in rural regions (BC Ministry of Health, 2005). Other then coordination with the community, health promotion upon this frail population should be continue.
Healthy life choices such as tobacco cessation, healthy eating, increased physical activity and injury prevention should continue to be promoted as these are the common unhealthy choices of BC seniors (BC Ministry of Health, 2005). Related community programs can be offer to patients for health promotion and sustainment purposes.
Organization
Organizations have a set of policies and procedures in regard to discharge planning. Organizations, like hospitals, has hired Care Management Leaders, such as myself to carry out the discharge policies and procedures. As a Care Management Leader, my responsibility includes initial assessment, arranging discharge follow-ups, connection with community, arranging community support, explanation of discharge papers and provision of community resources to a patient before his/her is discharge.
There are times when patient and patient’s family request for a long term care. The Care Management Leader (CML) must review the subsidized long-term care admission policy together with patients and their family, so they could understand the process. The other job that CML must do is to persuade the patient’s family and patient themselves that sometimes a long-term care is not the most ideal by presenting facts and experiences.
Policy
Vancouver Coastal Health (2017) states that a patient’s discharge planning must begin within the first 48 hours of patient admission, to prevent long length of stay for patient. If senior patients stay in the hospital too long, their physical functions may decline, and this will greatly affect the care that’s required (CIHI, 2012). In addition, patient’s wish must be respected. According to the Government of British Columbia (2015), patient’s decision must be respected and be heard. Patient has the right to refuse all care regardless of the reasons. As mentioned, if patient refuses to accept any services from any of the above level, all the previous work has to be reassessed and cancelled. If patient requests for long-term care, patient must be aware of the subsidized long-term care policy.
For admission from hospital to subsidized long-term care, patient and psatient'sfamily must provide evidences that home is no longer safe for patient to return to, and that all community services had been exhausted (Government of British Columbia, 2018). The CML also has to acquire approval from three directors of the hospital to complete the request.
As reference to the above factors, successful transition planning requires a great network of cooperation and collaboration. A flaw in one level, will create a negative impact to the other four levels, but if one level succeeds the subsequent levels may prosper. It is ideal to perfect each level's’ request but unfortunately there are still limitations, such as resources from the community. Because of limitations, a seamless transition plan will be hard to accomplish and as a result, hospital readmissions may continue, unless the government provides more resources to the needed areas or some innovative ideas had arisen. As CML, we continue to work towards the goal of seamless transition with the available resources and create innovative ideas to resolve the limitations. As a team, we will try our best and continue to perfect one’s social ecological model.
References:
BC Nurses Union (BCNU). (2015). Social Determinants of Health. Position Statement. Retrieved from: https://www.bcnu.org/AboutBcnu/Documents/position-statement-social-determinants-of-health.pdf
Canadian Institute for Health Information (CIHI). (2012). "All-Cause Readmission to Acute Care and Return to the Emergency Department". Retrieved from: https://secure.cihi.ca/free_products/Readmission_to_acutecare_en.pdf
Fayerman, P. (2018). B.C. has Second-Highest Hospital Readmission Rate in Canada; Solutions Elusive. Vancouver Sun. Retrieved from: https://vancouversun.com/news/local-news/b-c-has-second-highest-hospital-readmission-rate-in-canada-solutions-elusive
Government of British Columbia. (2018). Long Term Residential Care. Retrieved from: https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/long-term-residential-care
Government of British Columbia. (2015). Home and Community Care - Policy Manual. Retrieved from: https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/accountability/policy-and-standards/home-and-community-care-policy-manual
Russo, F. (2016). The Givers. Scientific American Mind, 27(6), 28. Retrieved from: https://0-doi-org.aupac.lib.athabascau.ca/10.1038/scientificamericanmind1116-28
Vancouver Coastal Health. (2017). Leaving the Hospital. Retrieved from: http://www.vch.ca/your-care/hospital-care/leaving-the-hospital
Vaughn, L.M., Jacquez, F., & Bakar, R. C. (2009). Cultural Health Attributions, Beliefs, and Practices: Effects on Healthcare and Medical Education. The Open Medical Education Journal, 2, 64-74. DOI:10.2174/1876519X00902010064
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