Leading Practices at Humber River Health

By Humber River Health

Health Standards Organization (HSO) and its affiliate, Accreditation Canada, have been identifying and publishing Leading Practices in the Leading Practices Library for over 15 years. 

A Leading Practice is an innovative, people-centred, evidence-informed practice that has been implemented by teams in an organization. The leading practice has demonstrated a positive change related to safe and reliable care/service, accessible and appropriate care/service, and/or integrated care/service.  

Below are Leading Practices at Humber River Health (Humber) that have been published in Health Standards Organization’s Leading Practices Library: 

Integrating Digitalization into the Delivery of a Peer Support Program at a Community 

In Humber’s Cancer Care Clinic, patients have identified a gap in a local peer support service. Emotional and psychosocial support are provided by the interdisciplinary team, however, it is common for patient-to-patient support to occur informally in the waiting room and treatment areas.  

In September 2021, the hospital’s Leadership Team approved a business case submitted by the Cancer Program’s Patient and Family Advisory Council (PFAC). In consultation with Humber’s Privacy Office and Quality and Risk Department, a framework was needed to ensure the exchange of personal information, sharing of community resources, linkages between the peer volunteer and the patient requesting support (Requestor), and documentation of the therapeutic interaction are kept confidential. Through collaborations with the Hospital’s Innovation Excellence Team, an online platform called HealixTM was used to develop these processes.  

External consultations took place with community partners on how to conduct a start-up program. A collaboration with Wellspring took place to develop a Peer Volunteer Training Curriculum. Six advisors participated in the designing and testing of a Peer Support App in the HealixTM platform. A pilot took place from October 2022 to April 2023, where patient Requestors used HealixTM to arrange appointments and connect with their peer volunteer. All participants indicated high satisfaction and effectiveness of the support program to help address their needs and concerns. The peer volunteers confirmed the importance of the local Program and the ability to use a platform for information sharing and documenting their interactions. The clinical team used HealixTM to monitor communication and review documentation.  

Seniors Care Strategic Plan 

Humber serves Northwestern Toronto communities, where 17-18 per cent of the population are seniors with 50 per cent living with four or more chronic conditions, and represent 71 per cent of hospital admissions. Achievement of the corporate 2017-2020 Strategic Plan direction of improving the health of the diverse community Humber serves included a key objective to develop and implement a senior-friendly strategy and continue to influence communication through leadership and partnership. Recognizing this priority, the planning and design of the innovative 2018-2021 Seniors Care Strategic Plan included a Seniors Strategic Retreat to engage over 50 internal and external stakeholders, which informed the development of the four strategic directions to:  

  1. enhance clinical care processes and services for older adults;
  2. enhance transitions across the care continuum to introduce best practice communication;
  3. grow and strengthen partnerships with community providers; and
  4. excel staff and physician competency in providing care for older adults. 

These 12 strategic objectives guided the implementation of over 20 seniors care initiatives, bringing in over $5.6 million in total funding from LHIN/OH, MOH, and Humber River Health Foundation. Humber’s 2023 Regional Geriatric Program Care Self-Assessment Report Card score of 82.5 per cent compared to Ontario Hospital’s score of 40 per cent, can be directly attributed to the refreshed 2022-2023 Seniors Care Strategic Plan. The ability for organizational spread centers on corporate governance and optimizing strong business acumen to support seniors’ strategy and make seniors care a priority, with quantitative data linking corporate priorities such as Equity, Diversity and Inclusion, bed flow, transitions, Ontario Health Teams and population health. 

Humber’s Elderly Assess and Restore Team (HEART) 

Launched in September 2018, Humber’s Elderly Assess and Restore Team, (HEART), an innovative mobile service operating seven days a week with both inpatient and outpatient components, was implemented to optimize patient function, reduce length of stay, facilitate home discharge, and promote health aging in the community.  

HEART is comprised of Occupational Therapists, Physiotherapists, Rehabilitation Assistants, and Registered Practical Nurses and serves a subset of “high-risk” seniors who have restorative potential and can benefit from Assess and Restore interventions.  Through the HEART program, patients are screened for eligibility and assessed upon admission. Once enrolled, patients are followed to discharge and receive post-discharge continuity of care.  Assessments use validated tools to ensure that HEART services are made available to the most complex and difficult-to-discharge patients who also have functional restorative potential.  

Electronic capture tools measure key performance indicators and gather patient and family input through surveys. From September 2018 to September 2021, HEART served 1109 patients. Of these, 98.3 per cent maintained or improved their functional capacity, an average of 36.7 per cent improved in function, and 87.7 per cent were discharged to their baseline.  Furthermore, HEART participants had a lower average length of stay when compared to similar non-participants (7.5 versus 12 days), resulting in saving of 4990 bed days and approximately $4.6 million in cost savings.  90 per cent of HEART participants reported that they would recommend this program to others. HEART helps patients maintain their independence in the community, improves inpatient capacity, and provides a basis for scale and spread. 

Long-Term Care and Acute Care Collaboration 

Reimagining care for long-term care (LTC) residents can enhance the utilization of healthcare resources and provide proactive interventions, improving resident outcomes and experience while optimizing scarce health human resources and improving provider experience. The LTC+ program, launched in April 2020 to enhance on-site care for LTC residents and prevent avoidable transfers to the emergency department (ED), is a virtual care model providing direct access to a nurse navigator, virtual physician consultations, specialist care, and community resources and has been scaled to Humber’s 11 affiliated LTC homes, supporting more than 2,200 beds.  

Launched in February 2021 in seven LTCs and scaled to two more homes in January 2022, the LTC Remote Monitoring, an innovative program, aims to deliver the best care possible to LTC residents and avoid unnecessary ED transfers. The program leverages the Practical Routine Elder Variants Indicate Early Warning for Emergency Department (PREVIEW-ED©) clinical deterioration tool developed from the evidenced-based NEWS2 scoring system that identifies early decline in the health status of LTC residents, focusing on four conditions: Pneumonia, Dehydration, Congestive Heart Failure, and Urinary Tract Infection. An integrated escalation process supports early intervention at home leveraging LTC+. The initiative resulted in a 35 per cent reduction in total ED visits, a 55 per cent reduction in ED visits for tool-sensitive conditions, a 36 per cent reduction in total hospital admissions, and a 32 per cent reduction for tool-sensitive condition admissions, equating to 7.32 acute beds, increasing capacity for acute patients as well as positive provider and resident/family experience results. 

Defying Delirium – Implementation of Best Practices in Delirium Care 

Delirium is an acute medical emergency and a significant predictor of morbidity, prolonged length of stay, and mortality among hospitalized patients. In accordance with Humber’s commitment to patient safety and best practices, and in response to a patient/family identified care need, the Seniors Care Team developed and implemented a Delirium Care Pathway for early prevention, detection, and management of patients at risk for Delirium in accordance with Ontario Health’s Quality Standard for Delirium Care. The core features of this pathway are the prevention of Delirium using non-pharmacological CHASM (Cognition and Perception, Hydration, Agitation, Sleep-Wake Cycle, Mobility) interventions, early screening using the validated Confusion Assessment Method (CAM) tool, management using both CHASM (1st line) and a Delirium Order Set (DOS) (2nd line), and delirium education for patients and families. Key processes included developing a multi-modal education and training program for staff, development and implementation of the DOS, which features suggested diagnostic tests and antipsychotic medications for provider consideration, as well as the development of a patient/family pamphlet.  

The Delirium Project was initiated as a pilot on the Acute Care of the Elderly (ACE) unit and went live on November 19, 2018. It has since been rolled out organization-wide to inpatient medical/surgical units, including to Humber’s Finch and Church Campuses. The Delirium Care Pathway has improved patient/family, and staff understanding and awareness of Delirium, improved care for patients at-risk of Delirium, and improved reliability of delirium screening and care delivery, with demonstrated CHASM and CAM completion rates above 90 per cent. 

Enhancing Timely Access to the Stroke Prevention Clinic Patients at High-Risk Transient Ischemic Attack (TIA) / Stroke 

Humber’s Stroke Prevention Clinic (SPC) Team, working closely with the Hospital’s Apotex Emergency Department Team, has refined and re-developed the Ontario Triage Algorithm for SPC Referrals in accordance with the Toronto Stroke Network’s Standards of Care. This helps us accurately streamline the quality of referrals to be seen by Humber’s clinicians in a timely manner and enhances the quality of clinical encounters. 

This project’s purpose was to enhance continuity of care and create a strategy that ensures patients will not be lost to follow-up. If a referral is declined, an SPC Rejection Notification letter is faxed back to the referring source and the patient’s primary practitioner. It states a clear statement for the ‘reason of rejection’ and includes helpful recommendations of where to refer patients as an alternative. Also developed was a referral ‘inclusion’ and ‘exclusion’ criteria list, included in the SPC Rejection Notification letter. This enables a more efficient and effective use of available resources. 

Previously, there was no standardized process for rejecting referrals. The enhanced strategy tremendously helps with timely patient care and allows patients at high risk of stroke / transient ischemic attack (TIA) to be seen at the SPC within the same day or the next business day, surpassing the current SPC best guideline recommendations. 

Humber is also optimizing the SPC order entry online referral by aligning it with the above process. 


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