Humber River Hospital serves the North West Toronto community, which has the highest number of seniors in Ontario, with this number expected to double by 2036. Patients aged 65 and above account for 38 per cent of hospital admissions and 65 per cent of inpatient census at the Hospital.
Humber River Hospital has recognized the need for a dedicated senior friendly strategy to better respond to the healthcare needs of its patient population. This strategy was established in 2018 and included the implementation of an innovative Assess and Restore (A&R) model of care -- Humber River Hospital's Elderly Assess and Restore Team (HEART), led by Beatrise Edelstein, Program Director, Seniors Care. A&R models in Ontario include short-term rehabilitative and restorative care treatments intended to increase the strength, mobility and functional ability for frail seniors. HEART offers a blueprint for scale and spread for hospitals looking to implement similar models.
HEART is an innovative mobile service that operates 7 days a week with both inpatient and outpatient components, and was implemented to optimize patient function, reduce length of stay (LOS), facilitate home discharge, and promote healthy aging in the community. It is comprised of occupational therapists, physiotherapists, rehabilitation assistants, and registered practical nurses and serves a subset of "high-risk" frail seniors that have restorative potential and can benefit from assess and restore interventions.
One of the many tiles utilized within Humber River Hospital's Command Centre is the Seniors Care Tile, which was created further to the implementation of the HEART program. The Seniors Care Tile monitors seniors that are eligible for HEART, promotes the resolution of delays in assessments and interventions, and allows for the rapid response to declining patient condition or function. This tile captures the number of senior patients screened and enrolled, and is monitored 24/7 by inpatient unit leads and the Command Centre staff. If an older adult patient is falling off their specialized plan, the staff at the Command Centre are alerted of this through the tile by the system's artificial intelligence.
Once patients are enrolled, the HEART team creates a specific discharge plan to ensure proper supports at home to bolster independent living and reduce caregiver burden. Patients and their families are engaged in assessment and goals setting as well as discharge planning. Prior to discharge, HEART staff review discharge plans and services with the patient and family, advocate for further needs, and seek patient consent to continue the outpatient stream of the program and initiates referrals to services as required. If a patient consents to outpatient follow-up, the HEART registered practical nurse conducts virtual visits by telephone with the patient upon discharge from the hospital.
Prior to the implementation of HEART, initiation of occupational therapy and physiotherapy services for frail high-risk older adults with restorative potential was dependent on a physician referral, which meant that patients could be waiting 48 hours or longer before receiving therapy. Patients, regardless of frailty or restorative potential, received therapy approximately 2-3 times per week, with no therapy delivered on the weekends. This led to the need for an A&R model like the HEART program. In order to monitor the quality improvements, health record data is utilized to capture LOS, readmissions, discharge destinations and visits to the ED following discharges. In addition, a focus group with HEART staff was conducted to determine the sustainability of the program and identify needed changes. A culture of continuous quality improvement was created by engaging all team members in formal reports and follow-up, building staff capacity.
From September 2018 to September 2021, HEART served 1,109 patients. Of these, 98.3 per cent maintained or improved their functional capacity, with an average 36.7 per cent improvement in function, and 87.7 per cent were discharged home to their baseline. Furthermore, HEART participants had a lower average LOS when compared to similar non-participants (7.5 vs. 12 days), resulting in savings of 4,990 bed days and approximately $4.6 million in cost savings. Ninety per cent of HEART participants reported that they would recommend this program to others, and approximately 87 per cent reported an overall positive experience with the program.
The HEART program provides direct impact to patients with improved functional ability, increased discharge home and positive patient experience. In recognition of the significant positive impact and effectiveness of this program, HEART was the recipient of the Canadian College of Health Leaders' 3M Health Care Quality Team Award- Quality improvement initiative(s) within an organization. This award recognizes teams for exceptional innovation, quality, patient and family engagement, and teamwork. The HEART program is a valuable initiative to be considered for implementation by other acute care hospitals for greater impact.