CC2H program keeps patients at home connected to care-givers

On a peaceful summer afternoon earlier this year, London, Ont., resident Jim Purchase was getting ready to head out to the movies with his wife when he started to feel “kind of funky.” Purchase, 67, was diagnosed with congestive heart failure in 2002 and ended up in hospital multiple times since then due to tightness in his chest and difficulty breathing.

This time the outcome was different. Instead of panicking to the point where he called an ambulance, Purchase phoned his Connecting Care to Home (CC2H) access number and spoke to a registered nurse who called up his latest medical information on her computer. He relied on her help to get his breathing under control and “was feeling 100 percent better” by the time he hung up.

“The main point is that I recognized I had to do something,” says Purchase.

CC2H is a new program administered by Ontario’s London Health Sciences Centre (LHSC) in conjunction with South West Local Health Integration Network (LHIN) Home and Community Care, St. Joseph’s Health Care London and Thames Valley Family Health Team.

Building on the success of the South West LHIN’s eShift Care program, originally launched to support medically fragile children and palliative patients at home, CC2H applies the same multi-disciplinary approach to improve the patient experience for those with chronic diseases, a group that often has higher rates of emergency department visits or readmissions following a hospital stay.

The first groups targeted by CC2H are patients diagnosed with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). The goal is to integrate patient care between hospital and home by engaging patients, and ensuring hospital, community and primary care teams are all on the same integrated care path.

Patients are identified in hospital and invited to join the program, which essentially provides “wraparound care for the patient,” explains Laurie Gould, Chief Clinical and Transformation Officer, LHSC.

“It’s really looking at the whole continuum of the patient journey … and is driving significant change around how we transition care to patients,” says Gould, noting that the program effectively applies both team and technology to enable self-care for patients. “There’s a good hand-off between the acute and community sectors, and it’s seamless,” she says.

On the hospital side, the transition to home is coordinated by a navigator. On the community side, a clinical care coordinator follows the patient home, providing a medication reconciliation and safety environmental scan while ensuring any home care required – such as physical therapy, occupational therapy or personal support worker care – is in place.

The hospital physician maintains ultimate responsibility for patients until they transition back to their primary caregivers, but clinicians in both organizations are part of the integrated care team.

Patients are provided with educational materials and 24-hour access to registered nurses. In some cases, they are also equipped with iPads, blood pressure cuffs and weigh scales.

Home care services are administered through the Victorian Order of Nurses under the direction of designated registered nurses. Videoconferencing – provided through the Ontario Telehealth Network – is used pre- and post-discharge, so that all members of the integrated care team can ‘virtually’ meet with patients and family members to go over next steps and confirm the care plan.

Throughout the CC2H program, everyone who touches a patient has 24-hour access to one patient file, updated in real-time with information related to key clinical indicators for COPD and CHF. Dr. Nasser Khalil, the CC2H project lead, calls it a “real-time, community bedside dashboard” and one of the program’s key success factors.

“The dashboard increases physician confidence as they are able to daily visualize, assess and predict patient needs rather than respond (when something goes wrong),” says Dr. Khalil, adding that it also provides shared accountability as patients transition across healthcare settings. “Technology allows for continuous physician support pre- and post-discharge and during the transition time from hospital to home which is the most anxious time.”

Clinical indicators for COPD and CHF include symptoms such as wheezing, chest tightness, mucous coloration, blood pressure and lack of energy – all of which are monitored daily by the patients and/or their in-home care providers. If physicians detect that a trend is worsening, they intervene and give orders to the registered nurse who is managing the patient file. Similarly, nurses and other members of the integrated home care team alert and consult with physicians when they have concerns.

The technology that makes the single patient view possible is a web-based service, developed and operated by London, Ont.-based Sensory Technologies, called eShift Clinic. Similar to eShift Care, and applying the same cascading delegation model of care, eShift Clinic is designed to support shorter, quicker visits to patients at home as opposed to the longer, overnight shifts required for palliative patients or extremely ill children.

Working in collaboration with the CC2H integrated care team, Sensory Technologies created forms and workflow to meet the requirements specific to COPD and CHF. The technology is capable of supporting additional care paths in the future.

Delivered as a software-as-a-service with strong service level agreements in place to ensure quick response times and high availability, eShift Clinic provides secure and scalable RESTful web services within a VMware virtual environment.

It is accessed on both desktop and mobile devices depending on the user’s role within the program; users log-in with a user ID and password and can view patient dashboards from wherever they happen to be. Registered nurses and physicians typically access the dashboard from desktop computers whereas home care providers in the field tend to use smartphones or tablets.

All members of the integrated CC2H care team leverage the dashboard to ensure “everyone is on the same page,” says Sherri McRobert, Manager, Telehomecare and Connecting Care to Home, at the South West LHIN. “It really gets down to good communication in a very complicated healthcare system.”

The process is further simplified because all branding is removed. Instead of having multiple phone numbers for multiple home care agencies, patients have one phone number to remember and use it for all inquiries, from something as simple as checking an appointment to a full-blown emergency situation. “They know that if they call the 24/7 line, they’re not going to go to voice mail, they’re going to get a nurse who’s going to pick up the line and look into their file,” she explains.

For Darcy Campeau, a 59-year-old London resident recently diagnosed with atrial fibrillation compounded by a brain tumour in his front left temporal lobe, CC2H is a “well-orchestrated” service that is keeping him “healthy and happy” at home.

After spending 10 days in hospital to treat his condition – a “double or nothing he can live without” – Campeau was discharged home with the support of his integrated CC2H team. As someone who lives alone, he says the program provides reassurance and helps to alleviate feelings of panic or anxiety.

Immediately after discharge from hospital, Campeau received home care visits twice a day. The schedule gradually expanded to one per day, then one every three days and eventually one per week until the home visits ended. Access to the 24/7 support line is ongoing.

He recalls one day when his vital signs were slightly off and the technician visiting his home called the registered nurse for direction. “The nurse at headquarters asked if I had taken my morning medication and I had forgotten to,” says Campeau. “They do their homework and make sure they’re on top of your case file. I was really impressed.”

Purchase, who uses an iPad to log his vital signs each day, describes the program as “hospital care, but at home.” He enrolled in CC2H in May, 2017, following a scare that sent him to hospital on his wedding anniversary. “I was sitting in Emergency and my wife was with me and my family, and I said ‘I really feel I should have been better prepared to understand what I need to do to avoid being admitted to hospital,’” he recalls. “A day or so later a nurse asked me if I was interested in the program to continue my care after I left the hospital, and I said that’s exactly the kind of thing I felt was necessary for me.”

For patients like Campeau and Purchase, CC2H alleviates the burden of “now what?” says Gould. “Patients want to get out of the hospital, but then reality strikes and it’s ‘My gosh! What am I going to do? What if this happens?” she says. “At the hospital, we do discharge teaching and we follow up with patients, but they don’t necessarily hear it all.”

Knowing there’s a virtual team watching out for early signs of distress and prepared to intervene to keep them healthy, patients in the CC2H program are free to focus on learning how to manage their conditions on their own, avoiding costly and sometimes unnecessary trips to hospital, she adds.

CC2H Clinical Care Coordinator Carol McLean says one notable change since the program’s introduction is that patients are beginning to “own” their conditions. Knowing they have the support of a 24/7 help line and a dedicated home care team working under the oversight of a physician gives them the confidence to recognize when their symptoms are changing and make pre-emptive adjustments, she says. “The facts are there to say they don’t need to go to Emergency. They have a better understanding of what’s going on.”

At the same time, CC2H involves a strong educational component. For COPD patients, for example, education might include smoking cessation or dietary assistance. When required, the team can also pull in social services to assist with finances or to fund medication.

“A lot of times patients have lived like this thinking nobody cares for such a long time, they’re quite overwhelmed when they see that there are people out there who do care,” says McLean. “Sometimes they are waking up alone and frightened and can’t catch their breath. They just call the number and we talk them down.”

One of the advantages to eShift Clinic is that it includes a data repository called eShift Central. Data is collected, stored and presented back to LHSC so that it can measure the CC2H program’s impact. In the first year, hospital lengths of stay are roughly 60 percent shorter, hospital readmissions within 30 days are down by 42 percent and overall costs related to emergency department visits, inpatient care and readmission have decreased 58 percent.

Due in part to its quantitative success, CC2H was named a recipient of the 3M Health Care Quality Team Awards for Quality Improvement Initiatives Across a Health System in June. Awarded by the Canadian College of Health Leaders, the recognition is based on three key elements: innovation, quality and teamwork. Donna Ladouceur, Vice-President, Home and Community Care, South West LHIN, says they are now exploring ways to expand the program, perhaps to other chronic disease populations or to support mental health.

“The opportunities are limitless with a platform like this. To me, this is where we need to go for chronic disease models across the province,” says Ladouceur. “Having specialist trained staff at the bedside is always a challenge, so being able to have the technology as a way to enhance that support at bedside with a virtual specialist is critical for us.”

Dr. Khalil would like to see the program standardized to suit every patient population. He sees it as an effective way to eliminate waste in the health care system and to empower patients at the same time. The main challenge is to engage primary care physicians who are solo practitioners and often prefer to receive patient updates via fax, he says.

“It’s a system problem, but it’s improving over time,” says Dr. Khalil, noting that primary caregiver participation in CC2H has increased from 50 percent to 90 percent since inception. “Patients feel supported when they see hospital teams, primary care teams as well as the home care team connected. They see that everyone is connecting and talking for their benefit.”

For further information regarding the CC2H program and underlying eShift technology platform, please contact Andrew Matthews who can be reached via email at Andrew.matthews@eshiftcare.com