Care Transition Patient Experience Study With Electronic Tool

Patients being admitted to hospital are becoming more complex and they often require a team of health professionals (doctors from different disciplines, nurses, and allied health professionals) working together to meet their needs. Effective communication among this team and with patients is essential to providing high quality patient-centered care. Care Connector is an electronic tool that was developed to help health professionals communicate about patient care with each other. It also incorporates best practice whenever possible (such as the used of Patient Oriented Discharge Summary \[PODS\] developed at University Health Network) during care transitions. We want to understand whether using electronic tools can address the communication issues faced by patients/families, and whether they impact on repeat visits to the Emergency Department or the hospital after discharge. In this study, we will be asking patients and families who have recently been discharged from hospital to describe their experience with communication and care transitions through a brief telephone survey. All of them will be discharged from units where Care Connector was used. However, some of the units would have used the PODS feature while others will not. A small group will also be invited to participate in an in-depth telephone interview. The results of this study will be used to improve Care Connector and to enhance communication and patient experience in general.

In this mixed methods study, we examine how electronic tools impact patient/family experience of communication in hospital and care transitions from hospital to home. Care Connector is an electronic interprofessional communication and collaboration platform initially designed to address communication challenges faced by interprofessional care team. It has been augmented to support care transitions through a care transition module (that include the generation of provider-facing discharge summary and PODS). This study examines the impact of this care transition module on patient/family experience of in-hospital communication and care transitions. The quantitative component is a controlled study where baseline data is collected on 4 medicine wards. The care transition module is then introduced to 2 of the 4 medicine wards (intervention) while the other 2 (control) wards continue to operate without the explicit use of the care transition module. Data is then collected again on all 4 wards to understand impact of patient/family experience, as well as objective outcomes of ED visits and re-admission within 30 days. A number of care transition process measures will also be obtained. In the qualitative component, we will interview patients/families, as well as healthcare providers to understand how technology can or cannot address these issues.

Eligibility Criteria:
Inclusion Criteria:

1. General medical patients cared for and discharged by the Hospitalist service
2. Be 18 years of age and above
3. Length of stay for hospitalization is at least 48 hours
4. The discharge destination is home (with or without support), or retirement home
5. Has the cognitive ability to, or has a substitute decision maker (SDM) (if patient is not capable) able to, provide informed consent for this research study
6. Can be contacted by telephone up to 30 days post discharge
7. Able to respond to survey questions over telephone (assistance from family member or other caregiver at the time of telephone survey is permitted)

Exclusion Criteria:

1. Discharged from a non-Medicine ward (e.g. medicine patient bed spaced to a surgical ward) or from the Emergency Department directly
2. Previously participated in this study (in case of re-admission)
3. Discharge destination is another acute care facility, rehab, palliative care unit, complex continuing care, long term care, or any other facility not listed in inclusion criteria 4.
4. Died in hospital
5. Unable to give informed consent due to language barrier and lack of suitable assistance from family members and/or caregivers and/or SDM (if patient is not capable)
6. Cannot be contacted by telephone after discharge
7. Unable to respond to telephone survey questions for any reason (e.g. hearing impairment, language barrier) and lack of availability of family members and/or other caregivers willing and able to provide assistance