MGH2Home: Integrating Interdisciplinary Care for Seamless Transitions from Hospital to Home

MGH2Home integrates the expertise of a hospital with three home and community care services organizations to form a unified care team under shared governance. This program targets adults designated as Alternate Level of Care in the hospital who need ongoing health and social support post-discharge. By focusing on determinants of health care planning, MGH2Home facilitates the transition of patients who would otherwise remain in the hospital, aiming to improve population health in East Toronto.Prior to discharge, the care team collaborates with patients and care partners to create a transitional care plan covering medical, rehabilitation, and social care needs. This plan continues into the community, adapting to changing needs. Post-discharge, patients receive comprehensive, multidisciplinary services at home. Regular team huddles and coordination with primary care providers ensure tailored support as clients recover and regain independence. Clients can remain in the program for up to 90 days before transitioning to less intensive support.The program involves community and patient representatives in all design sessions, addressing barriers and identifying innovative solutions. These representatives also serve on the Program Steering Committee, ensuring ongoing community involvement.In its first year, MGH2Home served 229 patients, with an average age of 79, conducting thousands of visits by Personal Support Workers, Nurses, Therapy Assistants, Social Workers, Occupational Therapists, Physiotherapists, and Pharmacists. Medication reconciliation was completed on all patients, revealing that 8% of patients had discrepancies or were taking inappropriate medications, with 90% of the pharmacist's recommended changes implemented.Since September 2023, early identification helped 25% of patients avoid ALC status, potentially reducing their hospital stays. Additionally, 60% of patients transitioned successfully back to their communities or traditional home care, with 3% showing improved functional levels.Patients and families have called the program a "lifeline" during the transition from hospital to home. Data indicates improved patient outcomes and preserved hospital bed capacity.Creating a One Team Approach necessitates a cultural shift for hospital and community care partners. Ensuring sustainability involves maintaining cross-partner collaboration, adhering to a shared vision and guiding principles, and using common metrics.The program's success relies on a dedicated team providing diverse services to patients with varying care complexities. Initial challenges included understanding capacity. A Power BI dashboard informed decision-making, leading to adjusted staffing levels in the coming year, including an increase in Personal Support Workers and the addition of a Program Supervisor within the hospital to support the transitional planning.Establishing a common workflow in a decentralized environment posed challenges. Early and thorough planning for centralized health information records and communication tools was crucial. The program uses a single scheduling platform called GoldCare, MS Teams for team communication, and a common repository for policies, procedures, and training.In the coming year, MGH2Home will leverage insights from its one-year evaluation as well as feedback from patients, families, and providers to refine the program. Efforts will focus on enhancing data governance, improving team communication, and collaborating with community programs and initiatives such as East Toronto Primary Care Response Team (PCCRT) and East Toronto Health Partners RNAO BPSO OHTs Transition in Care Best Practice Guidelines work.

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