Data Helps Match Clients to Appropriate Care

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CIHI is in the business of turning data into information for health system use. This means improving the health of Canadians by using data, information and analysis to make better decisions about our health system.

Here is an example of how information for health system use is translating into better client care at the Toronto Central Local Health Integration Network (TC LHIN), one of our health care partners.

The Problem: Clients (patients) in acute care, who have completed their treatment program, often wait in the hospital before they can move to more appropriate health care settings. In Canada, at any given time, these clients occupy about 5,200 beds. In Ontario, this translates to 7% of all clients in hospitals. The TC LHIN wanted to help transition these clients into more appropriate health care settings (including home with in-home services, long-term care homes and community support services) more quickly.

The Solution: The Resource Matching and Referral Program (RM&R) started in 2008 to equitably and efficiently transition clients to appropriate care while maximizing system capacity.

How does the RM&R work? Service providers in settings such as hospitals and community support service agencies enter client data into electronic referral forms. These capture the overall portrait of the clients and their needs. Staff in other facilities also indicate in the system which beds are available to be matched to clients. This standardized data is used to match clients, their needs and the most appropriate programs or services.

The TC LHIN has seen this program deliver results with strong collaboration among workers in different health care settings. RM&R has transformed health care in several ways:

Wait Times Down

Using RM&R data, a few strategies to combat long wait times in acute care emerged. These included proactively identifying clients at risk of having long waits (for whom alternate transition plans are developed by intensive case managers).

Now, the Toronto Central Community Care Access Centre (TC CCAC) reports that intensive case managers can better pinpoint at-risk clients and help transfer them to the right place, at the right time.

“With this information we can continue to further develop and refine the criteria for early identification and enhance the overall experience for our clients,” said Dionne Williams, TC CCAC’s Manager of Client Services.

Client Needs Understood

In 2011, the TC LHIN had an opportunity to fund new beds in one facility. It consulted region-wide referral data to see where gaps existed and which types of beds were most needed.

“Our referral data helped us better understand the needs of our clients and make changes to our care process,” said Rachel Solomon, TC LHIN’s Senior Director of Performance Measurement and Information Management.

Improved Referrals

Same-day referrals are referrals to home care that are initiated the same day a client is discharged from acute, rehabilitation or complex continuing care hospitals. This quick transition back home may cause clients anxiety because of uncertain service plans or care arrangements that help them reintegrate into the community.

RM&R data has enabled senior decision-makers to better understand same-day referrals. Now they can better plan for discharges and set up collaborative strategies. That could mean having a home care coordinator attend client rounds along with other care team members at the hospital to identify clients who may be ready to be discharged.

Since implementing such strategies, same-day referrals to in-home services have dropped to 29% (in March 2011) from 40% (in April 2010).

“I’m proud of the meaningful information to date and am excited about the progress we continue to make that will improve the quality of and access to care for clients,” said Camille Orridge, TC LHIN’s CEO.

Interested in how information can improve our health and health system? We’d love to hear your thoughts on the proposed Vision for Health System Use of Information in Canada.