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Guiding clients through every step of their journey of recovery

CIUSSS aims to provide care in a seamless continuum from one facility to the next

In describing the phases of their illness, people often refer to their experiences figuratively as a journey—from diagnosis through treatment to rehabilitation and, ideally, recovery. However, in many instances, an actual journey is also what they take—from home to hospital to rehabilitation centre (or long-term care) and, hopefully, back home again.

The crucial importance of both types of journeys—and the role of CIUSSS West-Central Montreal in ensuring a seamless continuum of care along the way—came clear to Harvey Powell in the months just after his life-altering stroke in early 2016.

During this unsettling period, Mr. Powell, 69, was robbed of his capacity to speak, swallow and walk—abilities he has largely regained through his own determination and the close cooperation among professionals in multiple CIUSSS facilities.

When the stroke hit in late March, Mr. Powell did not feel its full impact at first. He was riding in a friend’s car at the time, and all he knew was that something deeply troubling was happening—though what, exactly, had gone wrong was unclear.

Between exercise sessions to minimize the after-effects of his stroke, Harvey Powell relaxes in a lounge at the Montreal University Institute for Geriatrics.

“The next day, I went to my family doctor and I still wasn’t feeling well,” he recalls. “Suddenly, I started throwing up in his office and again in the hallway. I got to the washroom and he came running and said, ‘You’ve got to go to Emergency,’ which I did.”

At the Jewish General Hospital, a CAT scan revealed that a stroke had occurred, and now it was rapidly taking its toll: Mr. Powell found himself unable to swallow, and this was causing saliva and other secretions to collect in his throat. To provide life-saving relief, a tracheotomy drained the fluids, making breathing easier and giving him a limited ability to speak.

Several days in the Intensive Care Unit stabilized Mr. Powell’s condition and made it possible for him to be transferred to the JGH Stroke Unit, where the tracheotomy tube was eventually removed.

Two months of treatment and physiotherapy put Mr. Powell squarely on the road to recovery. “I had no voice at first, but it came back, thank God,” he says. “For a while, all I could do was write or point.” (In November, when Mr. Powell discussed his experiences, he was still unable to swallow food and was taking nutrition through a tube.)

What stands out in his memory of those weeks in the Stroke Unit is the compassion, attention and patience of the doctors, the allied healthcare professionals, the orderlies “and especially the nurses, who were tops—excellent, excellent, excellent. Nothing but praise for all of them.

“I’ve been back twice to visit and say thank you. And they remembered me like I was still there! They couldn’t believe how well I was walking, and they were genuinely thrilled.”

It was the staff of the JGH who also made sure that Mr. Powell had a smooth, timely and trouble-free transfer to the Richardson Hospital, another facility in CIUSSS West-Central Montreal, where more advanced rehabilitation was available. Although ties between the JGH and the Richardson pre-date the creation of the CIUSSS in April 2015, the network has strengthened the ability of staff to work closely together to determine the best course of treatment and rehabilitation for stroke patients.

Open channels between the two facilities also enabled Mr. Powell to be taken quickly back to the JGH Emergency Department when Richardson staff became concerned about his condition. However, the visit was brief and he soon found himself back at the Richardson, where six weeks of rehabilitation helped to restore his ability to walk.

The final step in Mr. Powell’s recovery was his transfer from the Richardson to the University of Montreal Institute for Geriatrics, where he has received therapy for his throat, tongue and jaw. “It was the Jewish and the Richardson that got me to this point,” he says. “Now I can walk, take a shower by myself, go to the bathroom myself, and do everything I need to by myself.”

Dr. Jeffrey Minuk, JGH Chief of Neurosciences, says a major advantage for patients like Mr. Powell is that, thanks to the unifying effects of the CIUSSS, they are now under the care of a single stroke team whose members are spread over various facilities.

Rosina Pasto gets a medical update from Dr. Jeffrey Minuk at the Jewish General Hospital.

Regardless of where they’re based, Dr. Minuk explains, staff regularly hold face-to-face meetings to improve their working relationship with one another, keep the lines of communication open, discuss specific cases, and ensure that patients are transferred seamlessly to whichever facility is best able to help them at any particular point in their recovery.

To make this possible, Dr. Minuk says, a number of initiatives have been implemented to streamline physician-to-physician communication. For example, if a family doctor at the Richardson is concerned about a patient, the physician is now assured of being able to quickly reach a JGH neurologist by phone, instead of having to send the patient to the JGH Emergency Department for an evaluation.

Another time-saver, Dr. Minuk adds, is that members of staff now all speak the same language—that is, they use a common set of evaluation tools. “What this means, for instance, is that when patients are evaluated before being transferred out of the JGH, they don’t need to be evaluated all over again when they arrive at the Richardson. Staff at the Richardson can hit the ground running, because they don’t need to spend two or three days getting to know the patient from scratch.”

“This has been an especially big step forward for our clients,” agrees Diana Chin, the Richardson’s Program Manager, who supervises rehabilitation for stroke patients and for neurology clients in the Geriatric Rehabilitation Program.

“By harmonizing the tools in all of our CIUSSS facilities, the user experience becomes much better, because clients aren’t getting fed up having to re-take tests,” Ms. Chin explains. “They’re eager to get started on their therapy as soon as possible, and this is what now happens. It reassures them that when they’re ready to be discharged, they’ll be well taken care of at home or wherever they’re headed next.” Ms. Chin says face-to-face familiarity among staff also speeds up discharge and transfer not just between the JGH and the Richardson, but among other facilities in CIUSSS West-Central Montreal, such as the Constance-Lethbridge Rehabilitation Centre and the CLSCs.

“If you’ve already met someone who’s on staff in another facility and you’re on a first-name, hi how-are-you basis, it’s much easier to get things done effectively over the phone,” she says. “It’s almost like working in the same building.”

These sorts of teams, known as integrated practice units, have proved their value not only for clients who have had a stroke, but for those with other types of medical conditions such as hip fractures, says Dr. Lawrence Rosenberg, President and CEO of CIUSSS West-Central Montreal.

For example, he explains, most older patients who need a hip operation are evaluated at home by a CLSC nurse before surgery, in order to determine whether they can return home after the operation, or whether they should first go to a rehabilitation centre.

Thus, the continuum for a typical hip-fracture patient might go something like this: Home evaluation by a CLSC nurse, surgery at the JGH, transfer to the Catherine Booth Hospital for rehabilitation, return home, and a re-evaluation by the CLSC nurse.

“This sort of arrangement existed before our CIUSSS came into existence, but it didn’t work as well as it could have,” says Dr. Rosenberg. “Now that we’re one organization with one philosophy, we can create a single team for hip fractures, which we’ve done. As an integrated practice unit, it can pull all of the necessary resources together under one roof, so to speak, and make that trajectory of care seamless.”

Dr. Rosenberg also notes that as the CIUSSS evolves, more integrated practice units will be developed to cover a greater variety of medical conditions. In addition, he says, the need for this seamless care is certain to increase, given the rising proportion of elderly patients who often have multiple difficulties.

“These days, very few people have a simple problem that can be dealt with in a single place,” he says. “It’s not like coming into the hospital with an appendicitis, they take out your appendix, and you go home. Most people have complicated problems, and since they frequently need to be seen in more than one of our institutions, that’s where this continuum becomes important.”

The ultimate objective is to ensure that the healthcare system is making every possible effort to accommodate itself to the needs of the patient, says Fabienne Germeil, Head Nurse in the JGH Department of Neurosciences.

“The goal is to make patients feel that they’re partners in their own care, which means they get a say in that care,” she explains. “It also means that patients should not feel like strangers when they’re transferred elsewhere for the next phase of care. A seamless continuum of care ensures that they know what will happen next and that they’ll be in the hands of professionals who are already familiar with their needs.”

Ms. Germeil adds that she has spent nearly 10 years working with stroke patients—including the past 16 months under the CIUSSS system—“and I see a real difference now, compared to what we were doing previously.

“What the CIUSSS does is enable all of us to work as a single team to view the patients’ needs from a wide perspective, while still concentrating on what is needed during every step of the process. That’s why, once an episode of care is finished in one facility, we get together and look at the next step.

“Our goal is that when a patient is ready to return to the community, he or she is able to function 100 per cent—or as close to it as possible.”