Partnership improves discharge planning for nine first nations

Dilico and Thunder Bay hospital work at addressing follow-up care challenges in remote communities

Discharge planning can be challenging in Northern Ontario for hospital patients going back to communities outside of major centres. Follow-up care, accessing services, and accessing certain medications can be difficult. Often, neither the discharging physician nor the patient understands that “following doctor’s orders” can sometimes be impossible within the community.

People living in First Nations have additional challenges including language and cultural barriers. Even those who speak English sometimes have difficulty with medical terms without an interpreter.

“We’ve seen the challenge of our clients being discharged without being prepared to go home to their community,” said Natalie Paavola, director of health at Dilico Anishinabek Family Care. “The gap was the hospital didn’t have that knowledge of our communities and the lack of resources in our communities.”

A unique partnership between Dilico and the Thunder Bay Regional Health Sciences Centre (TBRHSC) is helping overcome those challenges for nine of Dilico’s member First Nations by including Dilico discharge planners into the process.

“We proposed having our own discharge planners in the hospital because our nurses knew our clients, they knew our communities… and they knew the challenges of accessing the medications that were prescribed and following through on care orders,” Paavola said.

The TBRHSC does have patient navigators who play a vital role in helping Indigenous patients, many of whom are visiting a big city for the first time. Dilico’s discharge planners are all nurses and therefore are better equipped to explain care orders.

“The hospital’s navigators are not medically educated. They are not our ideal of a discharge planner,” said Monica Hemeon, home & community care manager at Dilico Anishinabek Family Care.

Dilico discharge nurses also add another layer of continuity of care clients may not have had otherwise. “We are able to follow up more with clients… as nurses in the hospital, we can track down doctors and figure out more, even when the person has been gone for a couple of days,” Hemeon said.

There have been several challenges. In essence, the two organizations are building a system that doesn’t exist anywhere and doesn’t easily fit into the current health care system. For example, patient confidentiality is obviously a key concern. Dilico as an outside organization cannot simply access Meditech software to see which clients may be an inpatient in the hospital. Patients accessing outpatient services such as renal care, the Fracture Clinic, and the Emergency Department complicate the situation further.

In short, the challenge revolves around communication and confidentiality. Hemeon said that there have been some discussions about identifying on patient charts that they are affiliated with a health care provider outside of a primary care provider such as clinics, home care, or organizations like Dilico.

“We have a system now where we identify clients via their postal code,” Hemeon said. However, it’s not a perfect system and patients can still get missed. Self-identifying has helped. “We’ve educated the community members to say, if you go in hospital, you need to connect with a (Dilico) discharge planner.”

Sometimes Dilico will learn about clients through family members or other ways as well. Dilico nurses also do rounds in the hospital regularly, and can identify clients that way. “That’s improving. Now we’re getting all outpatients as well. We’re capturing those clients who have short-term needs as well as long-term.”

Even if a patient’s medical record identifies the patient as requiring discharge planning with the assistance of a Dilico nurse, this is sometimes missed, especially after hours.

“We’ve done a lot of education with the hospital staff. I know the hospital has done some education about discharge planning. It has gotten a lot better than what it was even a year ago,” Hemeon said.

Funding is another area of concern. “It would be really helpful if we received ongoing funding for these positions,” Paavola said. “There is a process to submit a health services application to the LHIN for the discharge planners, which we’ve done.” The recent announcement to dissolve the LHINs could delay that process further.

Challenges aside, the partnership has dramatically improved discharge planning. More funding could open up the program to other First Nations.

“Because Dilico has been a leader in this, we are in the perfect position to be an appropriate resource to open it up to all Indigenous people who visit the Regional. That’s the position we’ve taken from the beginning, but we’ve focused on our nine First Nations because of the funding that we get,” Paavola said.

Filed in: First Nations, News

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