More than a third of patients discharged from St. Michael’s Hospital with complex medical problems are readmitted within 90 days at an average readmission cost of $11,000 per patient. Evidence shows that while a majority of patients discharged require ongoing medical attention, they don’t require emergency or hospital services. To reduce costs and focus on individual patient care, the Virtual Ward was created for patients at “high risk” for hospital re-admission.
“One of the most frustrating things about practicing inpatient medicine is that we take care of patients, and then we discharge them into a sort of void. We don’t really know what will happen to them afterwards,” explains Dr. Irfan Dhalla, a general internist at St. Michael’s Hospital and founder of the Virtual Ward. “Because this gap is so common, everyone on our team can tell you stories about patients who would have likely fallen between the cracks and ended up back in hospital without the virtual ward.”
To drive down the number of hospital readmissions, St. Michael’s Hospital partnered with the Toronto Central CCAC and several hospitals in the region to create the Virtual Ward, a program that uses a hospital-like approach to treat patients in their own home.
The Virtual Ward combines the best of the health care system –a multidisciplinary team of health care professionals and collaboration across local hospitals and community services. Patients in the Virtual Ward receive case management and medical support from the team, which integrates hospital, primary and home care. The Virtual Ward serves as a single point of contact with 24/7 availability for the patient in case of crises. The health care team also provides telephone support, dietary and medication counseling and in-home nursing if required.
Joakina Fernandes who lives on her own, was discharged from the hospital after being treated for a pulmonary embolism as well as COPD and CHF exacerbations. “I don’t know what would have happened without the Virtual Ward. I would have probably gone back to the hospital,” said Fernandes. “I used to volunteer as a gardener and now I will have the opportunity to go back to my plot.”
Since the program has been expanded to include Toronto General and Women’s College Hospitals, the Virtual Ward has admitted and treated more than 30 patients per month. And team members can point to numerous examples where poor health outcomes and unnecessary hospital readmissions have been avoided.
“The Virtual Ward takes the best elements of hospital care and applies them to patients living in their own homes,” said Camille Orridge, CEO of the Toronto Central LHIN. “The Virtual Ward allows us to create a new model of care, one that supports patients who are at high risk of readmission to hospital and their family doctors for a few weeks after hospital discharge.”
This innovative trial is still in the process of gathering data, but early results show that the Virtual Ward is working. Patients, specialists and family physicians have reported better patient results, a high quality of service and seamless coordination between health care providers.
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