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A Multi-Sector Team Leverages Technology to Support Safe Transitions at Home: An Ottawa East Ontario Health Team Collaborative Initiative

People living with congestive heart failure or chronic obstructive pulmonary disease and frail vulnerable older adults are examples of patients who have a prolonged stay in the hospital and who are frequent visitors to the Emergency Room. These patients unfortunately also have frequent readmissions to the hospital.

A virtual monitoring pilot program, currently underway in Ottawa and Prescott-Russell, may be part of the solution.

A six-month pilot project involving a collaborative partnership between Hôpital Montfort, Home and Community Care Support Services Champlain (HCCSS), and the Ottawa Paramedic Service, in collaboration with Ottawa East Ontario Health Team (OE OHT) and supported by Ontario Health demonstrates the value of a virtual monitoring program that is backed by Rapid Response Nurses and Community Paramedics. The program provides value to the patient, their family, and to the health care system. The Rapid Response Nurses and Community Paramedics are supported by Hôpital Montfort’s clinical team.

During the pilot, patients are enrolled in the Enhanced-In Home Remote Monitoring Program. Within 24-48 hours, a Rapid Response Nurse assesses the patient at home and connects with the patient’s primary care physician or nurse practitioner. A customized care pathway is established for each patient. Each morning, the patient reports their weight, blood pressure, oxygen saturation, and pulse, and answers a series of questions about their symptoms directly in a computer tablet that connects to a health software platform.

Between 8 a.m. and 8 p.m., a Rapid Response Nurse from HCCSS monitors the patient’s condition in real-time via the software. If an escalation is required, the nurse contacts the Community Paramedics for rapid intervention and Montfort remains available to support the team. Between 8 p.m. and 8 a.m., the Community Paramedic responds to patient/family calls and liaises back to the Rapid Response Nurse team.

Patient, family, and caregiver feedback has been very positive. Patients and staff have said the technology was easy to use and that it was easy to reach a nurse and/or a Community Paramedic during and after hours.

This program has increased access to beds in hospital, reduced emergency room visits, facilitated patient and family navigation through the complex healthcare system, and most importantly, provided a safety net for patients and families.

Therefore, we need to consider and build on technology and collaborative partnerships such as this to create future sustainable efficiencies in the healthcare system. Due to the success of this pilot, the program has been expanded to include the Prescott-Russell Community Paramedics.

Disclaimer: This backgrounder is intended for informational purposes only.