Access and Flow Table

The All Nations Health Partners Ontario Health Team (ANHP OHT) work collaboratively to support admission diversion, optimize available capacity, plan for surges, and enable smooth patient transitions within the community. Multiple ANHP OHT service providers are challenged to improve alternative level of care statistics and flow for the patients they serve across the ANHP service area. These efforts take place within a context of significant challenges, including health human resource shortages, funding pressures, and the need to better align services across organizations.

Goals and Priorities

The goals of the ANHP OHT Access and Flow Table are:

• ALC Prevention — ANHP OHT will work towards supporting community-based programs to keep frail seniors/older adults and other at-risk patients healthy in the community, prevent potentially unnecessary hospitalizations, and decrease overall acute care utilization. This is with the objective of reducing the flow of newly designated ALC cases and ALC cases within the ANHP OHT’s attributed population.

• ALC Management/Community Transitions — ANHP OHT will facilitate engagement and coordination of community partners to support seamless transitions of patients designated ALC back into the community. This is with the objective of reducing the length of stay and support seamless and timely discharge to the community.

ANHP OHT-led activities that align with the goals of ALC prevention and discharge management, including as part of their Collaborative Quality Improvement Plans (cQIPs). will be asked to collaborate. ANHP OHT will be asked to work with OH NW representatives to complete an ALC Action Plan. The region will provide ANHP OHT and the PCNs with additional guidance.

Priorities are:

• Early Identification and Assessment — Identified as a provincial ALC Leading Practices focus and aligns with provincial Home First and Delirium Aware Safer Healthcare (DASH) initiatives.

• Senior Friendly Care (sfCare) — Aligned with implementation of the provincial DASH campaign, a multi-year quality improvement campaign that aims to reduce hospital-acquired delirium.

• Proactive Transitions — Aligned with provincial implementation of the Home First approach, a province-wide initiative aimed at enhancing cross-sectoral collaboration throughout discharge planning to ensure patients receive the right care, at the right time, at the right place.