Grant: Project Grant

Elderly patients do not always receive the best care to help them return home after being discharged from the hospital. The connections between the hospital and community-care settings are often inadequate. As a result, elderly patients may be repeatedly readmitted to the hospital and their capacity to function may decrease. Caregivers may feel more burdened by the increasing care for their elderly loved ones. As well, healthcare costs increase. Mount Sinai Hospital in Toronto developed the Acute Care for Elders (ACE) program to improve healthcare for the elderly. By using innovative strategies such as transition coaches, follow-up calls and patient self-care guides, the ACE program reduced lengths of hospital stay and readmissions for elderly patients, increased patient satisfaction, and saved the healthcare system over $6 million in 2014. In 2016, the Centre intégré en santé et en services sociaux de Chaudière-Appalaches (CISSS CA) received funding from the Canadian Foundation for Healthcare Improvement and support from Mount Sinai experts to implement the ACE Program in one hospital in the CISSS CA with a focus on improving transitions between hospital and the community for the elderly. The goal of this research project is to implement the ACE Program in three other hospitals within the CISSS CA, using a "Wiki-suite" to help adapt and apply the ACE Program to each hospital. The Wiki-suite is an open-source collaborative database of knowledge tools and a training program which help clinicians share information and improve patient care. Our research project will evaluate how the ACE program implemented and improved care transitions for the elderly at these hospitals. We will also evaluate how the Wiki-suite helped adapt and apply the ACE program in participating hospitals.