Continuing Care
Healthcare providers are expanding their hospital-at-home programs
March 4, 2024
It’s been more than two years since Montreal’s Jewish General Hospital (JGH) launched its innovative hospital-at-home program (Hospital@Home) to help patients recover at home while being remotely monitored using digital technology.
What started as an effort to free up bed capacity and keep people safe during the pandemic is now a burgeoning multidisciplinary program, treating 800 patients from January 2022 to January 2024 with a 93 percent patient satisfaction score. Unanimous feedback is that virtual care is preferred over a hospital stay.
“We’re really aligning with the vision we have in our organization, which is to provide care everywhere,” said Erin Cook, director of Quality, Transformation, Evaluation, Value, Ethics and Virtual Care for CIUSSS du Centre-Ouest-de-l’Île-de-Montréal, the regional integrated university health and social services centre to which the JGH belongs.
There’s no magic recipe to follow, she added, but there are ingredients she believes are contributing to and supporting the successful rollout of hospital-at-home services at the hospital.
For one, the hospital has adopted a strong culture of innovation that encourages engagement and transformation. The organization is also certified in lean six sigma principles, and staff are trained in both value-based care and the Agile methodology for project management.
Transformation goals are supported from the top down, fostering strong collaboration between all professional teams. Home care nursing staff as well as medical partners from surgery, family medicine, emergency medicine, palliative care and cardiology are all playing an instrumental role in advancing Hospital@Home, said Cook.
Patient participation in the program remains voluntary. People are screened for admissibility based on their acuity and medical condition, and on the exclusion criteria set by each of practice area. To date, the hospital has 30 different trajectories of care that allow for safe transition of patient care from hospital to home, using the in-house command centre to help identify potential candidates and facilitate admission.
To help alleviate emergency overcrowding, for example, the JGH has created a direct admission from triage to Hospital@Home. Patients arriving in the ER who require short-term observation are able to return home under the remote care of an emergency physician, supported by whatever technology is required, including an iPhone or iPad that connects them to their virtual care team.
Hospital@Home is also helping to provide around-the-clock monitoring of palliative care patients, making it easier to keep people at home with their loved ones as they near end of life. “It’s a nice, patient-centred initiative,” said Erin. “It’s nice for families and it provides them with reassurance.”
Digital devices required to support people at home are prescribed by admitting physicians within each care discipline. Some patients may be issued automated blood pressure cuffs, finger probes for oxygen monitoring, and the BioBeat chest patch for continuous vital sign monitoring, while others may require a digital thermometer, weight scale or equipment to deliver IV therapies.
New in the past year is the introduction of point-of-care home testing for influenza, RSV and COVID-19 for vulnerable elderly, with the ability to onboard seniors directly to the Hospital@Home program if they test positive for illness and require medical attention.
The rapid evolution of virtual care within the healthcare organization has prompted the creation of other innovative services. For example, a tele-rehabilitation program enables people with chronic pulmonary disease to receive care from the comfort of home, and an innovative pilot program at a Quebec long-term care facility is using virtual reality goggles to help remote physicians administer care to 78 elderly residents.
“Whether they are needing regular checkups or something more serious, we don’t have to transfer them to hospital,” explained Cook, adding that the long-term care staff learned how to use the Microsoft HoloLens technology within hours.
“For the physician, it’s as if they are looking through the eyes of the staff member and they can go into Microsoft Teams and have an accurate visualization of everything in the room,” she added. The system also enables wound care specialists to remotely guide staff through procedures they don’t often encounter.
As an early adopter of Hospital@Home, the JGH faced several administrative challenges but has since worked through many of them. Cook credits strong support from the provincial ministry of health as a key contributor to their success, by allowing for physicians to use the same billing code for patients receiving virtual care that they do for hospitalized patients, for example.
Comparing a 20-bed hospital unit to a 20-bed virtual unit, Cook did the math to show annual operating savings of roughly $1.5 million and a staff reduction of 46 percent. Length of hospital stay has also decreased. “As we showed results and demonstrated the value we were creating, the ministry in turn funded our project,” she said.
Cook emphasizes that one remaining challenge is the lengthy regulatory approval process facing healthtech companies who are looking to advance their remote monitoring devices and are seeking approval from Health Canada to grow their services here. “It’s not the same business model as the U.S.,” she said. “There’s a shift happening, but it’s taking time for this technology to be adopted across the country.”
As part of its effort to free up hospital beds and improve the quality of healthcare in Quebec, the provincial government announced plans to roll out hospital-at-home services to eight health networks in the greater Montreal and Quebec City areas in May. An estimated $100 million is to be invested in the project over the next three years, demonstrating the value of the pioneering work accomplished by the JGH.
Manitoba is another Canadian province looking to expand virtual care. Last November, the University of Manitoba and the Health Sciences Centre (HSC) Foundation announced the creation of a new research hub dedicated to studying how technology can support patients in recovery, people with disabilities and older adults who want to live independently at home.
Jacquie Ripat, professor of occupational therapy at the College of Rehabilitation Science and vice-dean, academic affairs, of the Rady Faculty of Health Sciences, was appointed endowed chair of the new technology for assisted living (TAL) program.
Over the next five years, researchers will be exploring how existing and emerging technologies can be used to make living spaces more accessible for people with different needs.
The interdisciplinary projects include national and international collaborations primarily aimed at helping seniors and patients with chronic illnesses, rehabilitation or disability needs, as well as their families.
What’s exciting, said Ripat, is the creation of a smart living lab environment at the faculty of Health Sciences’ College of Rehabilitation Sciences. The virtual suite replicates everyday living quarters, including a kitchen, living room and two bathrooms, and is outfitted with lift systems, remote controls to operate lights, TVs and window coverings, smart floor mats and motion sensors to detect time, location and frequency of movement.
Whereas smart home technologies are sometimes viewed as a modern-day convenience, for those facing health challenges they can be life changing.
It might be as simple as using automated solutions to provide reminders to take medications, alert if a stove is left on, or enable someone to see who’s at their door before using a remote locking mechanism to allow entry, but the over-arching goal is to promote autonomy, participation and inclusion for people in need, she said.
The smart suite is both a place where researchers can test solutions and where patients can practice them. A future goal is to use the room as a temporary discharge suite, so that patients who are being discharged from the HSC rehabilitation hospital can trial equipment to see what solutions work best for them.
“There is an individual perspective that needs to be taken in all of this,” said Ripat. “It’s not just, go out to Best Buy, purchase a whole bunch of stuff and put it in place. It’s about knowing your physical, cognitive and healthcare needs – it’s a very complex picture.”
One project is exploring how smart home technologies can support people with brain or spinal cord injuries. Another study looked at kitchen designs to support aging in place by incorporating seated workstations, easy-access storage solutions and accommodation for mobility devices. Researchers are also considering how telepresence robots can be used to remotely support people living with dementia.
“If you had a robot in your older relative’s home … you would have the app on your phone and you could drive it to follow mom or dad, or to go look for something,” explained Ripat, noting that most robots are equipped with a computer tablet as a ‘face,’ so a loved one can see their caregiver’s face as they operate it.
“I think there are a lot of possibilities,” she added. “We’ll have to see where things go with price and availability. Acceptance will be a big one too.”
Research is also being conducted in a unique outdoor testing area where researchers can observe people using mobility devices as they navigate an obstacle course under different weather conditions. “There are labs that simulate winter, but this is ‘au natural,’” said Ripat. “It allows us to trial technology in authentic conditions, but in a safe place.”
As university researchers work to better understand how technology can serve as an interface between patients and the health system, the HSC Foundation intends to leverage their findings to support a broader rollout of virtual care services that were introduced during the pandemic.
The Virtual COVID-19 Outpatient Program (VCOP) launched in December 2020 with the foundation providing funding for the tablets, oximeters and thermometers to make it possible in the initial phase, enabling COVID patients to safely recover at home. Patients reported being “happy at home, in a comfortable, quiet place” while also feeling that they were “getting optimal medication attention.”
The TAL program builds on that success, said HSC Foundation CEO Jonathon Lyon. “It’s a matter of taking the program we have for assisted living and expanding it to a broader realm of virtual care. That’s really the next frontier,” said Lyon. “There’s no question that we know virtual care is a necessary component for healthcare going forward because we have these enormous demands.”
Lyon sees virtual care as one way to address hospital bed capacity challenges, as long as people continue to receive quality care. Moving forward, the foundation will continue to work closely with hospital leadership to identify future opportunities for virtual care, including studying ways to make some healthcare procedures more accessible to people living in rural communities or on remote First Nations.
“Whether you live five minutes from a care facility or five hours away, home is always a better option,” said Lyon. “The pandemic blew virtual care wide open and made it not something we were kind of interested in, but something we need to take the lead on.”
Ripat will also be focusing some of the research effort on training future health providers to start including home-based technology as part of their practice and thinking about it as a good option for their patients.
“It’s fine to have all of these technologies, but someone is going to have to provide that service, someone is going to have to make that match and help people figure out whether it’s the right technology, and how to use it and support it,” she said. “In a person’s life, interaction with the healthcare system is just a blip for the most part. Let’s reduce those blips and help them function in their lives the best they can.”