Preventing patients from falling through the cracks

Customer Story - Langs, The Working Centre, CMHA, Kitchener Community Health Centre, Stonehenge, Sanguen

Location

  • Kitchener & Cambridge, Canada

Use Cases Unlocked

  • Care coordination within internal team
  • Care coordination between services
  • Alignment on clinical tasks

Features Used

  • Clinical Messaging
  • Task Collaboration
  • Inter-organizational Communication
By Dr. Joseph Choi

Preventing patients from falling through the cracks

Health has long been understood to be determined by more than biology. While biology definite plays a role, there is overwhelming evidence that social factors play at least as important a role.

Dr. Craig Albrecht, a family physician in Cambridge, Ontario, gets it. He leads the Cambridge Interprofessional Care (IPC) team, a multidisciplinary group comprised of doctors, nurses, a social worker and outreach worker to provide preventative community care and services to patients. Their patient population has a relatively high concentration of patients who suffer from poverty, housing insecurity, substance use disorders, and mental health issues.

"We have a lot of people who are always on the move, and can disappear for weeks or months at a time," he explains. "This makes coordinating services and providing care for them in the usual way very difficult."



Adding to an already difficult job are the limited set of tools they have at their disposal to coordinate their diverse team. Explaining his challenges with connecting with his team, Dr. Albrecht describes:

"we were stuck using old tools, like faxes and pagers. Getting a hold of someone you knew was hard, let alone someone from an agency that you may not be familiar with. This led to a lot of wasted time chasing each other around."

Although commonly used tools such as text messaging is familiar and common in their personal lives, sending patient information via regularly messaging apps puts patient privacy at risk and violates healthcare privacy regulations. Sometimes providers would try to work around that by sending messages to each other hinting at which patient they're referring to, without divulging any identifying information. As one can imagine, this can create even more confusion.

This all began to change this past summer, when leaders at the Waterloo-Wellington Local Health Integration Network heard his frustrations, and started a pilot project with a secure mobile collaboration app from a Toronto-based healthcare startup called Hypercare. The application allows secure and compliant information sharing between providers on their personal mobile device.

"When we started showing other people the app, we were really surprised at how willing they are to use it," says Dr. Albrecht. "People are really keen on trying it. It's easy to use and they immediately see a reason for having it." As the IPC team used the app more and more, it caught the attention of other doctors wanting to join in to be more connected with the team and their patients. "It removes barriers to collaborating with colleagues and helps build a relationship. We've had other community workers approaching us to see how they can be connected on the app."

What started as a small pilot where all the users worked in the same office, the program has expanded to other healthcare organizations across the region, and even to users who you don't necessarily think of belonging in a healthcare team. "We have housing workers that we speak with directly to get our patients a place to stay. We even have a bail supervision outreach worker on our platform, because they are supporting their clients who need medical assistance from our team and sometimes that's the place they'll pop up first after radio silence for months."

There have been many success stories about how the app has improved their ability to provide total patient care. There have been cases where a non-healthcare provider was able to send a picture to the patient's usual doctor on the app to have a condition assessed and treated without needing to send them to a clinic or emergency department. But one example in particular comes to Dr. Albrecht's mind. "We had a patient who was an IV drug user and had unstable housing. He developed a septic joint and needed to go to the hospital." A septic joint is an infected joint, and if improperly treated, can result in loss of limb and even death. "He was admitted to the hospital, but left against medical advice before his treatment." The patient left because he had personal issues to tend to, but due to the serious nature of his condition, the hospital went out of their way to contact his usual care providers. "The emergency department manager called one of us asking about our patient, whom we knew well. We managed to get a hold of the patient and convinced him to go back to the hospital, and in the process the emergency department manager signed onto our platform so we could all communicate as a team. While he was in the hospital, we worked closely to set up housing and home care, including intravenous antibiotics."

Unfortunately, that wasn't the end of the story, as the patient signed out against medical advice again, before any of those services could be started. "We realized that he had left again, and it was a mess. But because were already communicating with the hospital team regularly, we were able to get specialists involved quickly and come up with an alternative plan. None of this could have come together so quickly with our old way of doing things."

The efforts of Dr. Albrecht and his team may seem heroic (and they are), but they happen every day in Ontario. Dedicated clinicians are using their own personal time to ensure that not only the best medical care is provided to their patients, but to ensure safe transition out of the hospital back into the community, and to address the many social determinants of health that often go ignored. As the province is developing new Ontario Health Teams, the story from Dr. Albrecht highlights the importance of communication and coordination in order to provide high quality care. To realize that goal, there needs to be a critical review on the outdated technologies and workflow processes that providers grapple with on a daily basis.

And while not as flashy as building a new hospital, a simple app can make all the difference.

We are proud to have Craig as one of our users.