A new tool in use by staff at Grand River Hospital and the Waterloo Wellington Local Health Integration Network (WWLHIN- opens in a new tab) is helping patients better manage their own care after leaving hospital.
The two organizations have piloted the University Health Network’s Patient Oriented Discharge Summary (PODS) in GRH’s low intensity rehabilitation program at the Freeport Campus. The system brings together discharge instructions, medication information and follow-up appointments in a much simpler manner for patients and families.
“A hospital is just one part of a patient’s health care journey. A great deal of care continues when a patient goes home, so patients and families need the best information to support them. We are very happy to have partnered with the Waterloo Wellington LHIN in piloting PODS, and look forward to sharing it further throughout our hospital’s programs and services,” said Judy Linton, GRH vice president of clinical services and chief nursing executive.
“Reviewing instructions and support plans with patients before they return home helps patients to better use that information in the community, know what to do to continue their recovery and know who to call if they have questions about appointments as well as home and community services,” said Joan DeBruyn, WWLHIN project manager.
PODS was designed for patients and health care providers to use together to discuss instructions for patients to follow after they leave hospital. These easy-to-understand instructions help make the transition to home for patients go as smoothly as possible. The summary increases the chance patients will follow post-hospital care instructions.
PODS highlight five important issues for patients leaving hospital:
- Medications they need to take;
- How they might feel and what to react;
- Changes to their routine;
- Appointments they have to go to; and
- Where to go for more information.
The PODS tool uses plain language, large type, pictures and images to make the information as easy to understand as possible. It’s available in 15 languages and includes space for patients to take their own notes. The summary is completed with the patient and their family, and the patient is asked to recall the instructions in their own words, to ensure they have been understood. In addition, a traditional discharge summary is still sent to the patient’s family doctor.
The PODS roll out was ideal in GRH’s low intensity rehabilitation program. Care providers serve a population of older adults with fractured hips, dementia and multiple medical needs. Staff including nurses, physiotherapists, occupational therapists, pharmacists as well as the LHIN care coordinator will complete parts of the PODS form. It’ll then be shared with the patient and their family members.
“Filling out a PODS form is very much a team effort. Many different health professionals can offer their input to each patient based on their unique expertise. We can go at each patient’s pace, and give them and their loved ones better support along the way,” said Julie Weir, GRH’s clinical manager for the low intensity rehabilitation program.
PODS was developed at the University Health Network’s OpenLab in Toronto. A report by the province’s Avoidable Hospitalization Expert Panel had found discharge instructions by hospitals were often poorly communicated because patients did not understand the medical terms, were not fluent in English, were not able to memorize instructions or were too stressed at the time of discharge to absorb information.
More than two dozen hospitals across the province have adopted PODS, potentially benefiting approximately 50,000 patients in the first year alone. This expansion is taking place with support from ARTIC (Adopting Research to Improve Care), a joint program of the Council of Academic Hospitals of Ontario (opens in a new tab) and Health Quality Ontario (opens in a new tab).