Table 1
Sub-Acute Care* Intervention Components.
| COMPONENT | DESCRIPTION |
|---|---|
| Service Purpose | To (1) provide quality care to patients who require daily individual assessment, general medical care, and interventions to enhance their functional, cognitive, psychosocial, and spiritual well-being; and (2) liaise with various community-based and institutional programs to facilitate out-of-hospital patient transitions. |
| Patient Profile | Adult patients 18+ years old with a general medical diagnosis and who have stable vitals; low/stable oxygen requirements; are unlikely to decompensate, and; do not require acute specialised hospitalized services. The target length of stay for SAC patients is 14–16 days. |
| Admission Pathways & Processes | SAC patients are admitted (1) directly from the onsite urgent care departments (primary pathway); (2) offsite from one of three emergency departments, or; (3) via transfer from an acute care medicine bed. A Central Bed Access service provides a gate keeping function, usually prioritizing direct onsite (urgent care) admissions. |
| Team Composition, Recruitment & Training | SAC patients are visited by an attending physician at least once daily and nursing care is provided by a mix of registered and licensed practical nurses. SAC teams are comprised of an extensive complement of allied health disciplines including clinical nutrition, speech-language pathology, occupational therapy, physiotherapy, pharmacy, respiratory therapy, social work, spiritual health and therapeutic recreation. Specialist consults from off-site programs such as psychiatry, geriatrics, and orthopedics are available as-needed. Hospital-based nurse case coordinators liaise with a range of community and institutional (e.g., nursing home) staff to facilitate out-of-hospital care transitions. SAC staff were redeployed from previously-undifferentiated (acute/sub-acute mix) hospital units. Teams received specialized training in dementia care and in use of the National Early Warning System (identifies patients at risk of clinical deterioration). Teams also received a patient flow guide, and an operations manual that defines roles, accountability, best practice procedures, and tools to help support & evaluate patient progress. |
| Care Planning & Communication | Care plans are initiated by the attending family physician within one day of patient admission. Four processes are used to support care planning, delivery & inter-professional collaboration. These include: 1)Daily Action Rounds: The entire care team meets daily to review care plans & to address barriers to patient discharge. 2)Complex Case Rounds: Teams have dedicated time to develop care plans (e.g., engaging with off-site staff) for particularly complex patients. 3)Bedside White Boards: These tools are used to communicate important information to the patient/family about care goals, to provide an estimated discharge date, and to name the care team members. 4)Patient Flow & Clinical Decision Software: All staff have access to real-time data on wait times, patient admissions, discharges and bed availability. Care plans, staff meeting dates, patient progress and barriers to discharge are updated continuously using clinical decision software. |
| Discharge Process & Criteria | Discharge planning begins at the time of patient admission and is supported by clinical decision software. Patients are eligible for discharge when: 1) Vital signs are stable, nausea/vomiting is controlled, pain is appropriately managed, oxygen saturation is above 90%, lab values are in an acceptable range, and patients are able to void sufficiently and independently (with or without support), AND; 2) Team members agree that the patient is ready for discharge from a functional, psychosocial and cognitive perspective. |
[i] * Termed “Lower Acuity Care” in the Winnipeg Health Region.
Table 2
Overview of Evaluation Domains, Data Sources and Study Timeline.
| PHASE | EVALUATION DOMAIN | DATA SOURCE | TIMELINE |
|---|---|---|---|
| Phase 1 | Healthcare Service Outcomes - efficiency, effectiveness of the intervention | Linked person-level administrative healthcare use records | Months 1–12 |
| Phase 2 | Implementation Outcomes - fidelity of the provider to the intervention | Medical chart audits | Months 12–16 |
| Phase 3 | Implementation Outcomes - acceptability and feasibility of the intervention - barriers and facilitators, strategies to enhance integrated care | Provider interviews | Months 16–24 |
| Patient/Informal Caregiver Experiences - measures of success and failure of the intervention, strategies to enhance integrated care | Patient/informal caregiver interviews | ||
| Phase 4 | Integration of the Results | Phases 1–3 | Months 24–36 |
Table 3
Administrative Datasets from the Data Repository used in this Study.
| REPOSITORY FILE | PURPOSE |
|---|---|
| Population Repository | This file defines registered Manitobans by key socio-demographic factors (age, sex, marital status, income quintile) and death date (using the Repository cancellation code). |
| Admission, Discharge, and Transfer File | This file provides date-stamped and bed-level hospital use data and will be used to (1) identify (using bed identifiers) SAC patients, and (2) define detailed hospital transitions pathways leading to and from SAC units. |
| Hospital Discharge Abstract Database | This file provides date- and site-stamped data on hospital use parameters, and up to 26 international classification of disease (ICD-10-CA) codes to define patient’s admitting diagnosis and complications that arise after hospital admission. |
| Emergency Department Information System | This file provides date- and time-stamped records of emergency department visits by site and patient acuity. |
| Medical Claims | This file provides date-stamped record on ambulatory care physician visits. One ICD-9-CM (clinical modification) code is provided per visit. |
| Home Care | This file provides the start- and end-date, volume and type of home care services received by each registered Manitoban (e.g., to identify prevalence [before SAC] and incidence [after SAC] home care users). Use of the Priority Home and Rapid Response Nursing programs are included in this overall file. |
| Nursing Home | This file provides the admission and exit date of nursing home use (to determine SAC disposition status). |
| Supported Living | This file provides the admission and exit date of congregate community housing use (to determine SAC dispositions status). |
| Drug Program Information Network | This file provides dispensation-level data on prescription drugs dispensed from retail (not in hospital) pharmacies (i.e., by their anatomical, therapeutic & chemical classification system). |