Background

Remote Care Management (RCM) refers to a model of care in which clinical teams and health care providers remotely support a patient’s care plan via virtual tools. Many existing RCM programs in Ontario have focused on supporting the care of patients with chronic disease utilizing remote monitoring and health coaching to empower patient self-management. RCM care models for palliative care, home dialysis and post-operative care are emerging across Ontario to offer new virtual care options to new patient groups. Looking toward the future, RCM will be an enabler for organizations to provide new and expanded virtual care options that empower patient self-management via programs that are accessible from their homes.

Need/Opportunity

St. Joseph’s Continuing Care Centre (SJCCC) has identified RCM as a strategic priority and this innovative model has been identified as a means of complementing our Inpatient Hospital Program. SJCCC has partnered with the Ontario TeleMedicine Network (OTN) to provide Remote Care Management to its Slow Paced Rehab Hospital Patients transitioning home. The initial rollout of this project will work with the team at OTN to create the first “Clinical Pathway” for Frail, Geriatric and at-risk transitions from Hospital to Home. This Pilot started in June 2020 andis the first program of its kind in Ontario. With this program, SJCCC aims to:

  • Maintain a “virtual” relationship with patients for 30 days once they are discharged Home. Our technology will enable remote monitoring and 2-way communication with the patient about their return home and adherence to their discharge plan.
  • Prevent Emergency Department Visits during this high-risk period upon discharge from Hospital.
  • Improve confidence and the overall patient experience by providing condition-specific health teaching.
  • Ensure that a smooth transition and warm handoff has occured to our partners providing care in the community.

How Does it Work? What can RCM Do?

All patients being discharged Home from our Slow Paced Rehabilitation Program will be assessed to determine if they are suitable candidates for this program. Patients who are suitable will be trained to use a mobile app on their mobile device which will enable the Remote Care. Patients without internet access or a mobile device of their own, will be loaned a “Health Kit” from SJCCC which will include a tablet, and any of a number of bluetooth health devices as necessary. The discharge planning team will then push the plan of care to the patients mobile app to ensure a succesful transition home. This discharge plan will be individually customized for each patient, but has the capability to include:

  • Remote “check-ins” and survey style questions (ex: did you pick up your next week’s medication) to ensure patients understand and are following their discharge plan of care.
  • Capturing vitals via bluetooth devices (Blood Pressure, Blood sugar, weight, pulse, Oxygen saturation, temperature).
  • Virtual visits via video calls with our Remote Care Team.
  • Secure Text messaging back to SJCCC.
  • Condition specific health teaching content and videos.

For more information about the Remote Care Program at St. Joseph’s Continuing Care Centre, please contact remotecare@sjccc.ca or call (613) 933-6040 ext. 22327.