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GGH partnering to provide better care to Chronic Obstructive Pulmonary Disease patients

June 21 – Two years ago when Guelph General Hospital (GGH) was developing its Strategic Plan it brought together a lot of information about the community it served. Over 600 people were surveyed and interviewed and community health information from sources such as Statistics Canada was analyzed to give an overall view of the health of those living in Guelph and Wellington County. Generally speaking, it is a healthy community but it did have its health challenges. For example, people with Chronic Obstructive Pulmonary Disease (COPD) were returning to the Hospital after being discharged again and again, at a rate much higher than they should.

To Melissa Kwiatkowski, GGH’s Director of Strategy and Risk Management, the numbers didn’t just mean extra pressure on the Hospital, they were a clear indication these patients weren’t getting the quality of care they needed. The Hospital reached out to the Guelph Family Health Team to partner and co-lead a community-wide process of understanding why this was happening and deciding what to do about it.

COPD is a chronic lung disease that causes clogged airflow from the lungs. Symptoms include breathing difficulty, cough, mucus production and wheezing. People with COPD are at increased risk of developing heart disease, lung cancer and other conditions.

The good news is COPD is treatable. With proper management, most people with COPD can achieve good symptom control and quality of life, as well as reduced risk of other associated conditions. So, it was possible to do better but it was going to take more than just the Hospital’s effort.

To just get a handle on the current state of the care being provided across the community, and to start brainstorming possible improvements, three half-day sessions were hosted at GGH. Among those at the table were representatives from the Hospital, the Guelph Family Health Team, the Guelph Community Health Centre, St. Joseph’s Health Centre Guelph, the Waterloo Wellington Local Health Integration Network and Guelph-Wellington Emergency Medical Service (EMS -ambulance). From those meetings, gaps in care were identified and plans made to help close them.

Thanks to this amazing partnership, readmission rates have gone down 40% in just one year – far exceeding even the most optimistic of predictions. “It’s been a fantastic coming together of all those involved, including patients and families,” says Kwiatkowski. “There’s still more to do but the progress that’s been made is quite remarkable.”

One of the significant changes made was simply making sure that COPD patients had an appointment booked with their primary care provider (such as their family physician) before leaving the Hospital. In addition to the follow-up appointment, the WWLHIN and EMS have partnered to pilot a program that provides patients with vital signs monitoring devices to use in their homes. Those devices will automatically send messages to the paramedics when there is a problem. The paramedics will work with specialized nurses from the Waterloo Wellington Local Health Integration Network (WWLHIN) to support the patient staying at home instead of a trip to the Hospital.

“Supporting an individual’s transition from hospital to Primary Care involves multiple providers and we could not have achieved these improvements by working in isolation,” says Ross Kirkconnell, Executive Director, Guelph Family Health Team.

Raechelle Devereaux, the Executive Director of the Guelph Community Health Centre echoed the partnership sentiment. “The work initiated by Guelph General Hospital has been an excellent example of how collective efforts result in collective impact,” she says. “Beyond reducing admissions, which our work together has certainly achieved, it has also resulted in strengthened relationships and an enhanced collaborative spirt across multiple organizations. If I could sum this up in a sentence, this effort has demonstrated that we are truly in this work together to advance better health outcomes for our clients.”