Organizations collaborate to monitor patients as they recover at home

BARRIE, Ont. – When a patient – often elderly – no longer requires acute care services in hospital, they can remain in bed for months as staff search for a place in a community or long-term care facility. Unfortunately, when these ALC (Alternate Level of Care) patients have prolonged hospitalization, they prevent others from getting a hospital bed, leading to delays and logjams in the healthcare system.

An innovative program at the Royal Victoria Regional Health Centre (RVH), in Barrie, is using technology to move these patients into their own homes and to monitor them remotely as they rehab safely and more comfortably.

“RVH@Home is a 16-week restorative program that creates a seamless transition of quality care from hospital to home,” said Dana Naylor, vice president, clinical. “It promotes patient independence after 16 weeks of rehabilitative care, in the familiarity of a patient’s home. They eat their own food, sleep in their own bed, all while being surrounded by family and pets.”

The program was established in November 2022 and to date has enrolled 350 patients. “Given the rate of referrals, we expect to enroll over 400 patients before our fiscal year end, March 31, 2024,” Naylor added.

Monitoring of patients in their homes is managed by Toronto Grace Health Centre’s Remote Care Monitoring (RCM) program – which launched in 2020 and has over 10,000 active clients in all five regions of Ontario. The main goal of the program is to help older adults stuck in hospital get back home living safely and independently.

“It’s about improving flow,” said Jake Tran, president & CEO, Toronto Grace Health Centre. “When patients can transition quickly to more appropriate care settings, they experience better health outcomes.

“And by providing patients with a combination of in-person and virtual care, coupled with 24/7 medical and non-medical monitoring, we’re helping them to avoid returning to an acute care facility,” Tran added.

The technology includes an SOS/falls pendant, worn around a client’s neck or wrist to detect falls, an emergency or patient wandering, and an automated medication dispensing device to help clients stay on track with their meds.

The pendants use GPS to create a virtual perimeter, safely tracking the movements of an individual at home.

“The pendants work on cellular two-way communication technology, and no cameras are used so patients maintain their privacy,” said Danielle Kilby-Lechman, manager, Remote Care Monitoring, Toronto Grace Health Centre. “If a patient falls or no movement is detected, or if a patient moves beyond a virtual barrier, an alert by text message is sent automatically to our 24-hour call Centre.”

At that point it will be determined if there is an emergency, or a false alarm, and staff can respond accordingly. In many cases, call Centre staff can assist clients without involving EMS. All alerts are documented and added to a client’s record.

A medication dispensing device works by dispensing multi-pouch medication strips pre-loaded into a dispenser cartridge. It ensures clients get the right medication dispensed at the right time. A musical alert tells clients when it’s time to take their meds, and if a dose is missed, an alert is automatically sent to Toronto Grace RCM 24/7 call Centre.

Care providers assisting patients in their home include:

• Registered Nurses (RN)
• Registered Practical Nurses (RPN)
• Personal Support Workers (PSWs); and
• Occupational therapists who help to execute a rehabilitation plan.

The nursing team is not from the hospital, but rather from leading home care agencies.

Patients receive a care plan upon discharge from hospital, so they know exactly which services they’ll receive for the first two weeks. During that time, patients receive visits from nurses or PSWs about two to three times per day. After this period, as patients improve, they may only require visits once or twice per week.

Being able to recover at home has many benefits. It provides patients with comfort and familiarity in their own surroundings; promotes a positive mindset, independence and improved overall quality of life.

Moreover, home care rehab programs cater to the individual needs of patients. “Therapists assess the home environment and tailor rehabilitation plans accordingly, ensuring that each patient receives personalized and targeted care,” said Naylor. “This unique approach enhances the effectiveness of rehabilitation, leading to faster and more sustainable recovery.”

Naylor added the program is progressing and evolving. Pendants are now provided to every patient, and remote care management is tailored to every patient’s needs. “RVH@Home forces us to think about patient care in a different way,” said Naylor. “It’s time to expand the ways in which patients receive care.”