Supporting patients after hospital discharge

The health care system is complex. Following a hospital discharge, patients sometimes have difficulty navigating the system. They can often find it challenging to reconnect with supports or understand where they are in their recovery. 

Strong research evidence shows if providers of care follow-up with patients, there are opportunities to support them in their journey and recovery. Knowing a provider is going to call reassures people they have not been forgotten and gives them the opportunity to reconnect. 

Lawson Scientist Dr. Matthew Meyer is leading a study with the goal of creating a routine process for following-up with stroke patients after hospital discharge and collecting patient-reported outcome measures (PROMs). The study is being funded through Lawson’s Internal Research Fund (IRF), designed to allow scientists the opportunity to obtain start-up funds for new projects with exciting potential. 

"The current challenge is we don’t typically follow-up with people after they’ve left hospital to access community supports. We have no way of knowing how they are doing once they’ve returned to the community,” says Dr. Meyer, who is also a population health strategist at London Health Sciences Centre (LHSC). “Our study focuses on filling this gap.”

Researchers will be collecting PROMs, which are outcomes experienced by the patient themselves. Typically, they focus on physical, mental, and emotional health and wellbeing, and quality of life. They provide more personalized information to the care team about the patient’s journey. 

Between 90 days and six months after a stroke, the team will reconnect with patients discharged from London Health Sciences Centre (LHSC). They’ll be asking questions about their health, personal experience and if they received services of care after discharge. The team will also be using standardized outcome measurements asking about quality of life and self-reported health. This connection allows patients to bring up any concerns that need to be addressed.

Extensive collection of these PROMs will help the team better understand the patient care journey in our region. It allows the team to compare how London patients are doing to people around the world in different settings. This information can be sent to local providers to promote system improvement.

“There is an international movement around collecting patient-reported outcome measures. Through the IRF, this demonstration project gives London an opportunity to tie into the movement and be leaders in that space while supporting our patients and improving care.” 

The research team has partnered with the Southwestern Ontario Stroke Network.

The IRF is designed to provide Lawson scientists the opportunity to obtain start-up funds for new projects with the potential to obtain larger funding, be published in a high-impact journal, or provide a clinical benefit to patients. Funding is provided by the clinical departments of London Health Sciences Centre and St. Joseph’s Health Care London, as well as the hospital foundations (London Health Sciences Foundation and St. Joseph’s Health Care Foundation).