How to support families when transitioning from critical care to home?
Bayshore Healthcare and Vancouver Coastal Health sought to bridge a critical funding divide preventing patients from accessing safe and effective transitional care services. Led by hospital transition team management and staff, together with RN home nurse managers, a patient transitional care program was created. At its core, families could now connect with a nurse to help transition from hospital to home. At-home registered nurses were installed to stabilize patients, at home. The problematic “revolving door” of home-to-hospital repeat visits was being addresses with the launch of an at-home community-based solution, led by families.
As a grassroots outreach marketing innovator, Bayshore Healthcare took a leadership role in the program. Key stakeholders, patients, families, were engaged to identify key areas where partnerships could eliminate bottlenecks and system inefficiencies. With patient needs and concerns as guide and compass, the home transitions program was built from the ground up. Messaging, marketing and outreach materials, community partners, were engaged at each step along the patient journey. Nursing staff were present to receive patients when they arrived home, at no charge to the patient or family. A traditional breaking point within the health care system was being addressed and remedied. Families themselves, with a health care system in support, took the lead in directing transitional care.