September 2018



We’re well into the month of September and I can’t help but notice the days getting shorter and the evenings becoming cooler!  On the upside, there is a sense of excitement and anticipation of fresh new beginnings with a new season just around the corner.  At the HNHB LHIN, we are excited about the opportunities ahead as we focus on even greater collaboration with our health system partners.


This month, I’m pleased to feature a guest blog by Martina Rozsa, HNHB LHIN’s Vice President of Home and Community Care.  In this edition, Martina discusses how continued collaboration and new innovations by the HNHB LHIN and its partners throughout the local health system are helping to ensure prompt access to care and smooth transitions for people at home, in hospital, long-term care homes or through community support service agencies.




Martina Rozsa

For many years, hospital overcrowding has been challenging for Ontario’s health care system, and the situation has become more challenging with our aging population as more people access care in hospitals.  And it isn’t just people who need surgery or those who are medically unstable and need round the clock nursing care.  Hospitals are now treating more people with exacerbated chronic illnesses and other ailments than ever before. 


The term “hallway medicine” is a reference to overcrowded hospitals where sometimes, seriously ill patients end up waiting for a hospital bed.  Another commonly used term is "alternate level of care" (ALC) patients.  These are people who have completed the acute or serious stage of their illness, are ready to be discharged from hospital but still need a certain level of support or services.  However, none or not all of the supports are immediately available outside of hospital and these patients end up waiting in hospital. 


At HNHB LHIN, we know that hospitals can’t tackle ALC pressures in isolation.  That’s why the LHIN home and community care team has been working together with our local hospitals to ensure smarter health care delivery by fine-tuning our processes and breaking down silos that have been past barriers to achieving greater success.  After months of ongoing collaboration and turning our thinking toward innovative approaches, we’re doing things differently to move the local health system on a different path – a direction that is laser-focused on making a significant improvement in delivering patient-centred care and creating an exceptional experience for the people we serve. 


Over the past number of months, HNHB LHIN has introduced several home and community care focused initiatives in hospitals, including implementing the new role of integrated hospital managers to help foster cohesion between hospital and LHIN home and community care discharge planning teams.  The integrated manager role helps reduce multiple handoffs and eliminates numerous approval layers within the hospital.  The integrated managers also make sure LHIN employees and hospital employees are functioning in sync as one team.

 Within the integrated teams, we’ve also had to change our thinking.  Instead of focusing on the barriers to a person’s successful discharge, teams are looking into every option possible to get patients back home.  By embracing the Home First philosophy, integrated teams are now thinking about the art of the possible instead of focusing on the impossible.  This means having conversations between the patient and family and the entire care team to ensure every available option is examined to ensure every patient has the opportunity to go home.

Equally important in this equation are the LHIN’s service provider organizations (SPOs) who are contracted to bring nursing care and personal support along with other professional service supports to people at home, in the community and at LHIN Nursing Care Centres.  SPOs are key players who have an essential role in discharge conversations with patients/families and their care teams.  By involving all parties in the conversation, communication becomes clear and consistent which helps limit confusion and anxiety among patients and caregivers.

As for ALC patients in our local hospitals, many are often seniors or people who are seriously ill and perhaps in the end-of-life stage who need intense care and services at home or in the community.  A large number of these people are unable to go back to the same living situation they had before entering hospital due to the extent of their medical condition.  Integrated discharge planning teams work together to help determine the most appropriate living arrangements for these people, in some cases with family members who are able to take on the formal caregiving role.


For those who don’t have the necessary support systems in place at home, the integrated care team works with traditional and non-traditional health system partners to explore supports available in retirement homes, supportive housing, assisted living, transitional care beds and long-term care for those who need 24/7 care and support.  With existing wait lists for these supportive care environments, the capacity in the community doesn’t always meet the demand immediately when the need arises, which results in a backlog of people waiting to leave hospital.


There are hundreds of successful hospital discharges happening every week across the local health system for people who need access to their physician, specialist, nursing care or therapy services.  It’s when an individual’s personal care needs come into play – specifically for older adults – that tough conversations have to happen.  Patients and their families may have to ask themselves: “What do we do next? Is it time for Mom and Dad to consider selling the house and move into a retirement community? Should they be thinking about long-term care?”  


What we do know for certain is: there is not one magic solution or silver bullet to solve hallway medicine and we have much work ahead of us to transform the health care system.  HNHB LHIN is doing everything possible to bring innovative solutions to the table.  We’ve made some positive headway already including changes to everyday business process and fundamental changes to our business and service delivery models to ensure patients can access the services they need.  We have been focused on building relationships and partnerships with our health system colleagues resulting in intensified collaboration to end the duplication of efforts within health care and build capacity across the continuum.  We are hopeful that patients and families have seen or will see a difference.

As we move forward to the future of our local health care system, HNHB LHIN will continue to engage with our communities and partners and remain focused on delivering safe, high quality care and support for the people we serve.  “Imagine what we can achieve together, when we care, listen and act!”


For more information about programs and services funded and/or provided by the HNHB LHIN, please visit us at or call 1-800-810-0000.


If you or your organization would like to be featured in a future blog or share a patient story in one of our Voices in the Community videos you can reach us through our office, or if you’re on social media via our Twitter handle @HNHB_LHINgage or on Facebook. Your feedback and questions are always welcome.