The goal of any patient-centred acute care facility is to provide quality inpatient care and then discharge healthier patients in a manner that reduces or avoids readmission.
In collaboration with Carefirst Seniors and Community Services Association and the Central East Community Care Access Centre (CCAC), The Scarborough Hospital (TSH) launched a ‘Virtual Ward’ program last May that successfully transitions a targeted group of our patients from hospital back home upon discharge.
Patients on our hospitalist units that are identified to be at high risk for readmission are referred to the Virtual Ward. These patients are eligible for the six-week Virtual Ward program.
“Through feedback from our patients, staff and leaders, we identified key gaps in the transition from hospital to home that inspired this collaboration between acute care and community organizations. The result of these gaps is that they often become ill again and are readmitted to hospital,” explains Nancy Veloso, Patient Care Director, Medicine, Geriatrics and Oncology at TSH.
“This approach has helped us identify opportunities to tighten the link back to the family doctor for follow-up, ensure patients are linked with the appropriate community support to review their medication questions and receive ongoing health education about their medical condition.”
Here’s how it works: Social workers from both TSH and Carefirst act as ‘Navigators’ who reach out to discharged patients to ensure they have filled their discharge prescriptions, and attended follow-up appointments with their family doctor or specialists.
They also point discharged patients in the right direction for ongoing health education available in the community.
“Patients who are at high risk of readmission or who may fall through the cracks in the community benefit from the Virtual Ward because the program ensures patients get the information and follow-up they need,” says TSH Social Worker Shannon Munroe.
“It’s a wonderful feeling to know that I am able to assist patients who may have difficulty managing at home, or who may have limited support.
“My role as a Social Worker enables me to speak with patients throughout their transition home and ensure that they are connected to appropriate community services, as well as encourage them to attend their follow-up appointments.”
One of Shannon’s clients, Hyacinth Black – whose husband Herman was discharged last fall – says the Virtual Ward was excellent.
“After discharge, we did receive follow-up from the hospital staff; they kept in touch with us to find out how he was doing, and to recommend community services,” Hyacinth says.
“It was really good; they were all so cooperative. And my husband hasn’t had to go back to the hospital since.”
“I followed up with Hyacinth for six weeks after her husband’s discharge and was able to help her with questions about his follow-up appointments, supports in the community and home care,” Shannon adds. “My experience with assisting the Blacks has been so rewarding.
“It’s great to know that with the assistance of the Virtual Ward, he and his family have been able to manage in their own home and have not had to return to hospital since.”
The initiative is also an excellent example of how TSH is working with its community partners to ensure patients are receiving ongoing care following discharge.