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Reimagining a transplant care delivery model
To serve more patients and extend lives without increasing the clinical team or significantly expanding the budget, the Ajmera Transplant Centre needed a new model of care. In collaboration with UHN Connected Care, which is dedicated to advancing integrated models of care, HHF supported the development of an ideal state service blueprint to improve the transplant experience and support patient and essential care partner self-management capabilities.
Client
UHN Ajmera Transplant Centre
In Collaboration with
UHN Connected Care
Services
Ethnographic Research, Co-Design Workshops, Service Design
Challenge
In recent years the Ajmera Transplant Centre (ATC) “care for life” model of care has become unsustainable due to significant growth in both volume of transplant patients and increasing readmission rates. On average, more than 600 new transplant patients enter the program each year while the ATC continues to manage the care of more than 7000 long-term transplant recipients. Increasing readmission rates has increased the demand for inpatient care and has exacerbated pressures on the clinical team and existing infrastructure, necessitating a change in the care delivery model.
Our team worked alongside the ATC Action Team (spearheaded by Connected Care UHN), which was composed of the transplant administrative team, representatives from each transplant organ group, and core transplant unit staff, to build an integrated transplant journey that would improve the patient experience and alleviate the increasing workload on transplant clinical teams.
- 600+New patients annually
- 7000+Long-term transplant recipients
- 800+Readmissions annually
Process
Discovery
Through multiple ethnographic observation sessions, interviews, and survey responses, we were able to explore the transplant experience from the perspective of patients, essential care partners (ECPs) and clinical teams. We were then able to map the day-to-day experience, processes and technology to identify critical gaps and opportunity areas.
Key insights highlighted the unpredictability and complexity of the transplant journey. In particular, patients noted that the early days setting up new routines following the transition home was a critical time of overwhelm and confusion. Clinical teams were noted as functioning within a vast, complex, and disconnected system of processes and communication channels that challenged their ability to provide the tethering that patients desired.
I felt very alone when I came home and in the months following the transplant. I was scared and worried. There were many days I thought there was something seriously wrong.
Transplant Recipient
Design
Building on the insights gained during the discovery phase, we collaborated with the ATC Action Team to build an ideal state vision for transplant care that was based on proactive assessment and patient self-management supported through a community care model.
The ideal state transplant experience was translated into a service blueprint and patient journey highlighting key interventions that would support the experience such as a patient journey tool, integrated education tools, home day check-in, 24/7 multi-modal support, a change in needs pathway, full team transplant rounds, and a community care model.
I remember taking all my meds out of the bag and laying them out on my dining room table and I cried...I believe there were 30 different meds and I thought what if I get one wrong?
Transplant Recipient
Outcomes
Our team developed an Ideal State Blueprint and Patient Journey Map that informed the implementation of an Integrated Care (IC) Pathway. The IC pathway provides the connection and support that patients and essential care partners need during the early transition home. There are also opportunities for proactive assessment and triaging when a change in need occurs through the IC Navigator role.
The IC and ATC teams worked in partnership to implement the initial use case of the IC Pathway in early 2023. Future phases of work will look to capitalize on the newly-launched EPIC system to support greater integration and consistency in clinical communication both internally and externally with community providers, including improvement of educational materials and the development of a patient journey tool through the EPIC patient portal.
