Towards Patient Centred Care Part 2: Virtual Wards and Good Old Fashioned Homevisits

Virtual Wards 

In Ontario more than a third of patients that are discharged from Intensive care wards are readmitted within 90 days. This readmission costs the Province $700 million dollars a year. Often, this is due to the service gap that exists between acute care and the modest care offered by home care programs.

Ideally, shouldn’t the system be redefined around the needs of the client?

A new pilot program developed by St-Michael’s Hospital, the University of Toronto, Women’s College Hospital, the Toronto Central Community Access Centre, the University Health Network and Sunnybrook Health Sciences Centre and led by Dr. Irfan Dhalla promises to do just that. The program is called the “Virtual Ward”. “Virtual” because it is mobile (contrarily to what you might think it is actually very low-tech!) and ward because they try to replicate everything that patients get when they are in a hospital bed: – a single-point of contact, 24 hours access to a doctor, a shared set of notes and an interdisciplinary team.

They apply these principles to patients who are being discharged but are at high risk of being readmitted in the next 30 days. Essentially, a care co-ordiantor is assigned to the patient immediately upon discharge and checks in on the patient at home just as if he/she were still in the hospital ward – taking temperature, blood pressure, checking tolerance and compliance with medication, scheduling further tests if warranted, even in some cases arranging for rehab.

Because they are performing a controlled experiment, which will assess both the success as well as the economic viability of the project, there is also a randomized selection process for the patients that meet the experiment’s criteria.

Upon discharge, the clients who have been selected are offered care on the virtual ward for the post-discharge period. Virtual ward patients are managed by a team led by a consultant physician. Other staff includes a ward clerk, a pharmacist, care coordinators and nurse practitioners. Medical consultants rotate onto the virtual ward team for three-week blocks at a time. Every morning at 8.30am, the virtual ward team meets for an office-based ward round to discuss clients and assignments.

The virtual ward staff also collect files from any other care providers the patient might have (with consent from the patient) as well as exchange information. Members of the team may visit patients at home but they also encourage their clients/ patients to phone them with any question or concerns. The patients are “discharged” when the team feels they are ready, but only after ongoing care with their primary care physician and community based care teams has been fully established and organized.

The program has been operating for a year so far and has successfully helped many patients who might have otherwise fallen between the cracks and doctors returning from rounds in the virtual ward are reporting that they are have much more control over their discharge planning than they previously had done! Not only is it a great care-model, but it is also a fantastic learning tool for medical personnel!

Now THAT is client centered care. But it is not an entirely new and novel idea. We have known that health care teams (HCTs) promote better outcomes and people who really know and care about seniors have said that they need more primary care at home.

Housecalls

Dr. Mark Nowaczynski is a Toronto-based geriatric doctor who has been saying this for at least a decade. He himself does house calls despite the fact that there are considerable disincentives for him to do so. He is the subject of Ian McLeod’s 2004 documentary “House Calls”.Click here for more information on this documentary. He says that in the 1930s, 40% of all doctor-patient encounters were housecalls. With the ageing population and the expansion of the home care sector, that percentage has counterintuitively continued to drop, reaching 0.6% in the 1980s and even lower rates throughout the decades that followed. These are curious statistics since primary health care at home just makes sense.

There are exceedingly few doctors that do it, mostly physicians who work with seniors are doing home visits out the goodness of their heart. There currently are no incentives for doctors to provide home visits, it certainly isn’t economically viable. Health care delivery and training, Dr. Nowaczynski explains, are highly centralized. The current model is office based and there is a lack of training and exposure to home-based care. Although British Columbia just increased the fee for housecalls to $106, this is still considerably less than a doctor would make sitting in his office seeing back to back patients.

The few doctors who do provide housecalls say that seniors are much better cared for at home. Too often, they say that in hospitals they are overtested, poorly diagnosed and overmedicated. It is so simple yet it makes sense. Good old fashioned house calls. They could do our strained healthcare system a world of good.

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