The CICC is continuously developing innovative solutions to improve the process of care for patients living with complex medical issues. We are a Centre dedicated to using an interprofessional model to collaborate, develop, and implement new best practices that will positively impact both patients and care providers in inpatient as well as community settings.
The system currently lacks sufficient community-based initiatives that provide the necessary follow-up care and support required by our complex medical patients after hospital discharge. The Virtual Ward (VW), developed in collaboration with our partner hospitals and the Toronto Central Community Care Access Centre, presents a solution to this problem and has the potential to drive system change that will be cost effective and reduce the occurrence of avoidable readmissions, keeping patients out of the hospital for non-emergency situations.
Presently, patients receive high-intensity care once admitted into hospital. Yet typically after hospital discharge, there is a decrease in the intensity of care provided to complex medical patients, which contributes to readmissions.
Patients in the VW reside at home and benefit from care provided by an interdisciplinary team with an internist, community nurse practitioner, hospital nurse clinician, pharmacist, case managers, and team assistant. The VW team has a single point of contact and is available to patients 24/7. The Virtual Ward takes the best elements of hospital care and applies them to patients living in their own homes, in an attempt to integrate care across the primary, community and acute care sectors for a few weeks after hospital discharge.
To evaluate the VW, a pragmatic, randomized controlled trial (rCT) has been implemented. Patients admitted to General Internal medicine are currently being recruited from St. michael’s Hospital, Toronto General Hospital and Toronto Western Hospital of uHN, and Sunnybrook Health Sciences Centre. Patients at high-risk of readmission are identified using the lACe index, which determines risk based on length of stay, acuity of admission, comorbidities, and emergency department visits.
The trial is currently in the data collection phase. The trial will end once 1500 patients have been enrolled. Results of the study are anticipated to be available in 2013. It is our goal that improving coordination and continuity of care for complex medical patients will reduce avoidable readmissions to hospital.
To learn more about the Virtual Ward, visit: www.virtualward.ca.