Virtual Ward up and running
Sunnybrook has joined a city-wide trial of a new model of care called a Virtual Ward, which provides support and care for patients in their homes after they’ve been discharged from hospital. This “hospital without walls” pilot targets patients at high risk for hospital re-admission by ensuring that they receive coordinated care after leaving Sunnybrook.
While at home, patients participating in the Virtual Ward have access to a care team that includes a general internal medicine physician, a pharmacist, nurses and a care coordinator, all of whom work together with the patient’s family physician. A 24-hour hotline number provides patients with quick and easy access to the care team. The trial is comparing patients who receive Virtual Ward care and usual care. To date, approximately 500 patients have been recruited across Toronto for the trial, with a goal of enrolling a total of 1500 patients.
At this time, general internal medicine patients on D2 at Sunnybrook are eligible for ‘admission’ to the Virtual Ward, with an expansion to other general internal medicine patients in the hospital over the summer. The process begins in the hospital and involves communication between the discharging unit, the Virtual Ward team and the patient. Patients ‘admitted’ to the Virtual Ward must be referred prior to discharge and meet specific criteria, which includes the use of a scoring tool developed that identifies patients at high risk of re-admission.
“Being discharged from hospital can be a very challenging and complex time for patients,” explains Dr. Rajin Mehta, a general internal medicine specialist at Sunnybrook. “It’s overwhelming for patients to absorb all of the information they need prior to discharge. And typically there is no scheduled contact with anyone on their healthcare team until their follow-up appointment three or four weeks after they are discharged. The Virtual Ward allows for much more support and access to care, typically for the first two to six weeks after leaving the hospital.”
The Virtual Ward is a collaboration with three other Toronto hospitals (St. Michael’s Hospital, University Health Network and Women’s College Hospital) and the Toronto Central Community Care Access Centre. Core funding is provided by the Toronto Central Local Health Integration Network and the Ministry of Health and Long Term Care, with additional funding from the physician alternate funding plan (AFP). The research is primarily funded by the Canadian Institutes of Health Research.
The Virtual Ward model of care supports Sunnybrook’s strategic goals in the area of quality of patient care. “This is a senior-friendly care initiative that focuses on providing reliable, safe and patient-centred care,” says Dr. Brian Wong, a general internal medicine specialist at Sunnybrook. “The main goal is to improve health outcomes and reduce complications by supporting patients and their family physicians.”
Dr. Mehta has been the attending physician for the Virtual Ward and values the opportunity to bring care to people’s homes. “There are a lot of frail, elderly patients and by applying more coordination and resources there is the opportunity to avoid hospital readmission which is so costly. I have seen firsthand cases where patients are treated efficiently and avoid calling an ambulance, an emergency visit and eventual readmission.”
Final results for the Virtual Ward trial are expected in about two years. “This model of care is really looking at how we can help the system by getting the right information to the right person at the right time on behalf of the patient,” adds Françoise Ko, project manager for the Virtual Ward.
To learn more about the Virtual Ward, please visit the website www.virtualward.ca.
