Not everything needs to be #Innovative in Healthcare...a patient of mine who was admitted after being kept at home for almost 2 years with end stage kidney disease and cognitive impairment. How did we do it?

#GoalsofCare - at the time of diagnosis of their CKD we discussed what their goals were. The outcome of that discussion, no dialysis and a decision to stay at home and avoid both acute and long-term care as long as possible while managing any symptoms or medical issues

#NeedsatHome - we then identified what the PATIENT needed. Not what we thought they needed. What was the outcome? Cleaning, medication delivery, meal delivery and social support. How did we do that? A coordinated #CommunitySupportService Response

#SafetyatHome - given the patients chronic disease and cognitive impairment regular visits at home and streamlined communication with primary care were needed. How did we do this? An integrated #communityparamedicine response and regular visits

#ReassessandIterate - over the last 2 years we have worked with the Patient AND Family to work together to adjust the plan to meet the patients ongoing and changing needs as finances, social situations and health status are always in flux.

#AlwaysThere - Together as a #Team with a dedicated @SouthWestLHIN coordinator, #CSS and @MLPS911 #CP team we have provided near 24/7 support to this patient and kept them at home with #zero ED utilization until a recent fall..

#WarmHandOff - Despite the challenges that can occur with acute unexpected events like falls we have worked with the admitting team and emailed updates, included all team members and provided collateral history to help the inpatient team with discharge planning from day 1.

This thread is not about #healthcareinnovation. Its about #dedication, #trust, #communication and #accountability which are the values we need to cultivate within ourselves and between each other.