2010 Award Finalist

4R Model of Care

Category - Improving Integration

The Problem

When a patient is occupying a bed in a hospital and does not actually require the intensity of resources or degree of service provided in that care setting, he or she is designated Alternate Level of Care (ALC). ALC patients are a concern because they divert resources from patients who need them more, and cause backlogs and waiting times. During the fourth quarter of 2007-2008 and first quarter of 2008-2009, Timmins District Hospital experienced high volumes of Alternate Level of Care (ALC) patients, resulting in a severe bed shortage crisis. More than half the hospital's acute care beds were occupied by ALC patients and almost 75 percent of ER stretchers occupied by admitted patients. There was a significant and disturbing increase in ER wait times.

The Innovation

In response to this crisis, the Timmins and District Hospital (TADH) team implemented the 4R Model of Care – Right thing at the Right time for the Right person and producing the best Result. The program consisted of the following four key strategies that were developed and implemented over a period of six months:

• A Geriatric Emergency Screening Program through which at risk seniors are identified and linked to community services and supports as appropriate. The program serves to maintain seniors in the community for as long as possible thereby reducing the number of Emergency Department (ED) visits and avoidable hospital admissions.
• A wrap around service program that assessed ALC patients and patients at risk of becoming ALC to determine what services they need.
• A Flo Collaborative, which is a provincial imitative aimed at improving processes of care to achieve timely and effective patient transitions from medical units of acute care hospitals to the community.
• A Clustered ALC Unit, in which ALC patients occupying acute care beds were aligned into a clustered 12 bed area on the Medical Unit. This strategy allowed for an enhanced model of care for both the ALC patients and acute care patients on the unit.

The Results

The 4R Model of Care program met or exceeded all of its targets.
Objective #1 was to reduce the number of ALC days in acute care by 30 percent. A 38 percent reduction in the number of ALC days achieved.
Objective #2 was to reduce the percentage of acute care beds occupied by ALC patients by 40 percent. A 78 percent reduction was achieved.
Objective #3 was to reduce the average wait time of admitted patients in ER by 60 percent. That was achieved.
Objective #4 was to reduce the number of patient days in ER by 50 percent. A 74 percent reduction in patient days in ER was achieved.

Next Steps

The 4R Model principles have been integrated into the Timmins and District Hospital Quality Framework, which forms the basis of the organization's Quality Improvement Plan (QIP). Modifications to the clustered acute care unit are ongoing and aimed at achieving a more flexible model of care where patients are effectively and efficiently transitioned from ER to acute care.